Survey of patients' experiences and perceptions of care provided by nurse and pharmacist independent prescribers in primary care

Background

In the United Kingdom, nurses and pharmacists who have undertaken additional post‐registration training can prescribe medicines for any medical condition within their competence (non‐medical prescribers, NMPs), but little is known about patients'' experiences and perceptions of this service.

Objective

to obtain feedback from primary care patients on the impact of prescribing by nurse independent prescribers (NIPs) and pharmacist independent prescribers (PIPs) on experiences of the consultation, the patient–professional relationship, access to medicines, quality of care, choice, knowledge, patient‐reported adherence and control of their condition.

Design

Two cross‐sectional postal surveys.

Setting and participants

Patients prescribed for by either NIPs or PIPs in six general practices from different regions in England.

Results

30% of patients responded (294/975; 149/525 NIPs; 145/450 PIPs). Most said they were very satisfied with their last visit (94%; 87%), they were told as much as they wanted to know about their medicines (88%; 80%), and felt the independent prescriber really understood their point of view (87%; 75%). They had a good relationship with (89%; 79%) and confidence in (84%; 77%) their NMP. When comparing NMP and doctor prescribing services, most patients reported no difference in their experience of care provided, including access to it, control of condition, support for adherence, quality and safety of care.

Discussion and conclusions

Patients had positive perceptions and experience from their NMP visit. NMPs were well received, and patients'' responses indicated the establishment of rapport. They did not express a strong preference for care provided by either their non‐medical or medical prescriber.     

Putting the ‘patient’ in patient safety: a qualitative study of consumer experiences

Background Although patient safety has been studied extensively, little research has directly examined patient and family (consumer) perceptions. Evidence suggests that clinicians define safety differently from consumers, e.g. clinicians focus more on outcomes, whereas consumers may focus more on processes. Consumer perceptions of patient safety are important for several reasons. First, health‐care policy leaders have been encouraging patients and families to take a proactive role in ensuring patient safety; therefore, an understanding of how patients define safety is needed. Second, consumer perceptions of safety could influence outcomes such as trust and satisfaction or compliance with treatment protocols. Finally, consumer perspectives could be an additional lens for viewing complex systems and processes for quality improvement efforts. Objectives To qualitatively explore acute care consumer perceptions of patient safety. Design and methods Thirty‐nine individuals with a recent overnight hospital visit participated in one of four group interviews. Analysis followed an interpretive analytical approach. Results Three basic themes were identified: Communication, staffing issues and medication administration. Consumers associated care process problems, such as delays or lack of information, with safety rather than as service quality problems. Participants agreed that patients need family caregivers as advocates. Conclusions Consumers seem acutely aware of care processes they believe pose risks to safety. Perceptual measures of patient safety and quality may help to identify areas where there are higher risks of preventable adverse events.     

Initiating decision‐making in neurology consultations: ‘recommending’ versus ‘option‐listing’ and the implications for medical authority

This article compares two practices for initiating treatment decision‐making, evident in audio‐recorded consultations between a neurologist and 13 patients in two hospital clinics in the UK. We call these ‘recommending’ and ‘option‐listing’. The former entails making a proposal to do something; the latter entails the construction of a list of options. Using conversation analysis (CA), we illustrate each, showing that the distinction between these two practices matters to participants. Our analysis centres on two distinctions between the practices: epistemic differences and differences in the slots each creates for the patient’s response. Considering the implications of our findings for understanding medical authority, we argue that option‐listing – relative to recommending – is a practice whereby clinicians work to relinquish a little of their authority. This article contributes, then, to a growing body of CA work that offers a more nuanced, tempered account of medical authority than is typically portrayed in the sociological literature. We argue that future CA studies should map out the range of ways – in addition to recommending – in which treatment decision‐making is initiated by clinicians. This will allow for further evidence‐based contributions to debates on the related concepts of patient participation, choice, shared decision‐making and medical authority.     

Early intervention services in daily family life: mothers' perceptions of ‘ideal’ versus ‘actual’ service provision

Although the occupational therapy and early intervention literature espouses a family-centred approach to intervention, families have rarely been asked about their experiences of these services. This paper describes a qualitative study that aimed to identify and explore parents' perceptions of occupational therapy services and the impact of these services in their daily family life. Ten mothers of children (aged 0–6 years) with disabilities and high support needs completed questionnaires and semi-structured, in-depth interviews. Analysis revealed that mothers thought in terms of early intervention services in general, rather than in terms of occupational therapy specifically. Mothers used early intervention services primarily to enhance their child's abilities, while considering what was best for their family and, as a lesser priority, themselves. Ideally, relaxed and friendly service providers were perceived as having a greater insight into daily family life, and therefore a greater capacity to provide services to meet family needs (e.g., flexible, home-based services). However, the mothers in this study did not experience many ‘ideal’ characteristics of services and service providers, suggesting that changes are needed in occupational therapy practice and in the education of therapists. Implications for occupational therapy education and practice are discussed in the context of the family-centred literature, and recommendations are made for future research with families. Copyright © 1998 Whurr Publishers Ltd.     

‘Good’ patient/‘bad’ patient: clinical learning and the entrenching of inequality

This article develops sociological understanding of the reproduction of inequality in medicine. The material is drawn from a longitudinal study of student experiences of clinical learning that entailed 72 qualitative in‐depth interviews with 27 medical students from five medical schools in the USA. To highlight the subtle, yet powerful, ways in which inequality gets entrenched, this article analyses ideas of the ‘good’ and the ‘bad’ patient. Bad patients question not only biomedical knowledge but also medical students’ commitment to helping people. Good patients engage with medical students in a manner that upholds biomedical knowledge and enables students to assume the role of the healer and the expert. At the same time, good patients possess cultural skills that align with those of medical practitioners. This alignment is, furthermore, central to definitions of the good patient. Distinctions drawn between good and bad patients thus both embody as well as enforce social inequality. The subtle reproduction of inequality is, however, difficult to discern because judgements about patients entwine with emotion.     

Exploring identity in the ‘figured worlds’ of cancer care‐giving and marriage in Australia

Following changes in the structure and funding of the Australian medical system, patients have become ‘consumers’ or ‘clients’. Family and friends have become ‘carers’ or ‘caregivers’, signifying their increased responsibilities as patients move from hospitals to communities. While policy makers embrace the term ‘carer’, some argue that the title is not widely recognised and has disempowering connotations. This paper examines spouses’ reflections on the term ‘carer’ based on qualitative interviews with 32 Australians caring for a spouse with cancer from a study conducted between 2006 and 2009. Recruitment involved survey and snowball sampling. Following a grounded theory approach, data collection and analysis were performed simultaneously. Using Holland and colleagues’ sociocultural ‘identity as practice’ theory and a thematic approach to analysis, findings depict identification with the ‘spouse’ and ‘carer’ label as relationally situated and dependent on meaningful interaction. Although others argue that the term ‘carer’ is a ‘failure’, these findings depict identification with the label as contextual, positional and enacted, not fixed. Furthermore, and of most significance to practitioners and policy makers, the title has value, providing carers with an opportunity to position themselves as entitled to inclusion and support, and providing health professionals with a potential indicator of a spouse's increased burden.     

‘Treat them into the grave’: cancer physicians’ attitudes towards the use of high‐cost cancer medicines at the end of life

The prescribing of high‐cost cancer medicines at the end of life has become a focus of criticism, due primarily to concerns about the safety, efficacy and cost‐effectiveness of these medicines in this clinical context. In response to these concerns, a number of interventions have been proposed – frequently focused on improving physician–patient communication at the end of life. Underpinning these strategies is the assumption that the prescribing of high‐cost cancer medicines at the end of life is primarily the result of poor communication on the part of cancer physicians. In this paper, we explore the factors perceived by cancer physicians to be driving the use of high‐cost cancer medicines at the end of life. Drawing on semi‐structured interviews with 16 Australian oncologists and haematologists, we demonstrate that these physicians believe that the use of high‐cost medicines at the end of life is driven by multiple factors – including individual, interpersonal, socio‐cultural and public policy influences. We conclude that these factors, and their interactions, need to be taken into account in the development of public policy and clinical interventions to address the use of high‐cost medicines at the end of life.     

Patients' participation in decision‐making in the medical field – ‘projectification’ of patients in a neoliberal framed healthcare system

This article focuses on patients' participation in decision‐making in meetings with healthcare professionals in a healthcare system, based on neoliberal regulations and ideas. Drawing on two constructed empirical cases, primarily from the perspective of patients, this article analyses and discusses the clinical practice around decision‐making meetings within a Foucauldian perspective. Patients' participation in decision‐making can be seen as an offshoot of respect for patient autonomy. A treatment must be chosen, when patients consult physicians. From the perspective of patients, there is a tendency for healthcare professionals to supply the patients with the information that they think are necessary for them to make their own decision. But patients do not always want to be a ‘customer’ in the healthcare system; they want to be a patient, consulting an expert for help and advice, which creates resistance to some parts of the decision‐making process. Both professionals and patients are subject to the structural frame of the medical field, formed of both neoliberal framework and medical logic. The decision‐making competence in relation to the choice of treatment is placed away from the professionals and seen as belonging to the patient. A ‘projectification’ of the patient occurs, whereby the patient becomes responsible for his/her choices in treatment and care and the professionals support him/her with knowledge, preferences, and alternative views, out of which he/she must make his/her own choices, and the responsibility for those choices now and in the future. At the same time, there is a tendency towards de‐professionalization. In that light, participation of patients in decision‐making can be regarded as a tacit governmentality strategy that shapes the location of responsibility between individual and society, and independent patients and healthcare professionals, despite the basically desirable, appropriate, and necessary idea of involving patients in their own situations from a humanistic perspective.     

Front‐line perspectives on ‘joined‐up’ working relationships: a qualitative study of social prescribing in the west of Scotland

Cross‐sector collaboration has been promoted by government policies in the United Kingdom and many western welfare states for decades. Literature on joint working has focused predominantly on the strategic level, neglecting the role of individual practitioners in putting ‘joined‐up working’ into practice. This paper takes the case of ‘social prescribing’ in the west of Scotland as an instance of joined‐up working, in which primary healthcare professionals are encouraged to refer patients to non‐medical sources of support in the third sector. This study draws on social capital theory to analyse the quality of the relationships between primary healthcare professionals and third sector practitioners. Eighteen health professionals and 15 representatives of third sector organisations participated in a qualitative interview study. Significant barriers to collaborative working were evident. The two stakeholder groups expressed different understandings of health, with few primary healthcare professionals considering non‐medical sources of support to be useful or relevant. Health professionals were mistrustful of unknown third sector organisations, and concerned about their accountability for referrals that were not successful or positive for the patient. Third sector practitioners sought to build trust through face‐to‐face interactions with health professionals. However, primary healthcare professionals and third sector practitioners were not connected in effective networks. We highlight the ongoing imbalance of power between primary healthcare professionals and third sector organisations. Strategic collaborations should be complemented by efforts to build shared understandings, trust and connections between the diverse front‐line workers whose mutual co‐operation is necessary to achieve effective joined‐up working.     

Valuing whole complex lives: Young adults’ experiences of recovery‐related principles in mental healthcare in the United States

One in five young adults (aged 18–25 years) in the United States experiences a past year mental disorder, commonly including depression or anxiety. Yet, 1.5 million each year do not receive needed mental health services and are unlikely, in general, to seek formal mental healthcare. We aimed to inform the development of a novel programme for young adult mental health by first eliciting their positive and negative prior experiences with mental health providers. Four focus groups with 19 young adults (aged 19–26 years) recruited from the community and with moderate to severe depression and/or anxiety were conducted in 2018 in a western US state. Participants’ prior experiences with services/providers were elicited along six pre‐defined recovery‐related concepts: feeling listened to and validated, inclusivity, full information and consent, hope and optimism, connectedness, and change. Focus groups were audio‐recorded, transcribed verbatim and uploaded into NVivo version 12 software. Two independent coders used deductive thematic analysis to identify patterned responses. Feeling listened to and validated appeared as a cornerstone of other recovery concepts. Participants discussed past negative experiences with psychiatrists and regret for being put on medications in their teenage years without information or options. Hope and optimism were low because of a general focus by professionals to address immediate symptom‐based issues, rather than on improving their overall lives. Service providers’ focus on medication‐taking, and other one‐size‐fits‐all tools, was interpreted as lacking a sincere desire to help. Young adults were particularly sensitive to inauthentic interactions and superficial strategies, which left them craving care that incorporated their whole lives, acknowledged biopsychosocial interconnections and prioritised improving their lives over ‘feeling better’ in a given moment. Mental health providers should consider developing programmes that shift focus away from an exclusively medical understanding of distress and towards holistic, educational or relational approaches that value body, mind, self‐exploration and authentic connection.     

A studentized permutation test for three‐arm trials in the ‘gold standard’ design

The ‘gold standard’ design for three‐arm trials refers to trials with an active control and a placebo control in addition to the experimental treatment group. This trial design is recommended when being ethically justifiable and it allows the simultaneous comparison of experimental treatment, active control, and placebo. Parametric testing methods have been studied plentifully over the past years. However, these methods often tend to be liberal or conservative when distributional assumptions are not met particularly with small sample sizes. In this article, we introduce a studentized permutation test for testing non‐inferiority and superiority of the experimental treatment compared with the active control in three‐arm trials in the ‘gold standard’ design. The performance of the studentized permutation test for finite sample sizes is assessed in a Monte Carlo simulation study under various parameter constellations. Emphasis is put on whether the studentized permutation test meets the target significance level. For comparison purposes, commonly used Wald‐type tests, which do not make any distributional assumptions, are included in the simulation study. The simulation study shows that the presented studentized permutation test for assessing non‐inferiority in three‐arm trials in the ‘gold standard’ design outperforms its competitors, for instance the test based on a quasi‐Poisson model, for count data. The methods discussed in this paper are implemented in the R package ThreeArmedTrials which is available on the comprehensive R archive network (CRAN). Copyright © 2016 John Wiley & Sons, Ltd.