Participant characteristics are described in Table 1. Twelve podiatrists and one podiatric surgeon were recruited into the study. Of the 13 participants 9 were female with a of median of 13.5 years of podiatry practice (range 1 to >30) reported. Most participants were based in South Australia, with two from Queensland and one each from Western Australia and Victoria. Participants worked predominantly in private practice, with two identifying public sector workplaces and one person working in academia. The majority of participants were based in metropolitan practices, 3 identified as rural or regional practitioners. Of the 13 participants, three were endorsed prescribers and three were in training. Of the participants who were non-endorsed, three were willing to become endorsed, two were neutral on the subject, one was not willing to become endorsed, and one participant preference was not reported.
Table 1: Participant characteristics
Participant ID
|
Years since graduation
|
State of practice
|
Type of employment
|
Region of employment
|
Endorsed prescriber status and pathway to endorsement
|
P1
|
> 30
|
VIC
|
Full-time
|
Metropolitan and regional
|
Endorsed (Pathway A)
|
P2
|
3
|
SA
|
Full-time
|
Metropolitan
|
In-training (Pathway B)
|
P3
|
8
|
SA
|
Part-time
|
Metropolitan
|
In-training (Pathway B)
|
P4
|
8
|
QLD
|
Full-time
|
Metropolitan
|
Endorsed (Pathway B)
|
P5
|
2
|
WA
|
Part-time
|
Metropolitan
|
In-training (Pathway B)
|
P6
|
10
|
SA
|
Full-time
|
Metropolitan
|
Non-endorsed
|
P7
|
12
|
SA
|
Full-time
|
Rural and regional
|
Non-endorsed
|
P8
|
8
|
SA
|
Full-time
|
Metropolitan
|
Non-endorsed
|
P9
|
>30
|
SA
|
Full-time
|
Rural and regional
|
Non-endorsed
|
P10
|
28
|
SA
|
Full-time
|
Metropolitan
|
Non-endorsed
|
P11
|
1
|
SA
|
Part-time
|
Metropolitan
|
Non-endorsed
|
P12
|
20
|
SA
|
Part-time
|
Rural and regional
|
Non-endorsed
|
P13
|
16
|
QLD
|
Full-time
|
Metropolitan
|
Endorsed (Pathway B)
|
SA- South Australia, VIC- Victoria, QLD- Queensland, WA- Western Australia.
Super-ordinate themes
Three super-ordinate themes were found that incorporated both the barriers and facilitators and are listed with their sub-themes in Table 2. A description of each super-ordinate theme is provided below with supporting quotes.
Table 2: Sub-themes and super-ordinate themes
Super-ordinate themes
|
Subthemes
|
Competence and autonomy
|
Facilitators
Broaden scope of practice & better patient care
Rural location
Prior knowledge
Job security and competitiveness
Not wanting to be left behind
Barriers
Conservatism- no perceive need for the increased scope of practice
Concern it may compromise the level of competence
|
Social and workplace influences
|
Facilitators and barriers
Access to mentors
Access to supervised training opportunities
Workplace setting
Workplace and social networks
Facilitators
Working with an endorsed prescriber
Barriers
Small number of podiatry prescribers
Lack of patient awareness and stigma of being ‘toenail cutters’
Lack of formalised structure
Easy access to other prescribers
Rural location
|
Extrinsic motivators
|
Barriers
Time
Stage of life and career
Lack of Financial reward
Lack of PBS funding
Knowledge of the process
Endorsement not completely incorporated into undergraduate training
Facilitators
SARS-CoV-2 (COVID-19)
|
Theme 1: Competence and autonomy
Feeling competent as a practitioner and developing a broader scope of practice were highly reported themes. The drive for competence was closely related to a desire for autonomy, or a sense of being able to take direct action that will improve a patient’s outcome. Participants described complete patient care and improve patient outcomes as being central in a desire for autonomy.
“Yes, I would like to become an endorsed prescriber ….because I'd like to broaden my scope of practice and have the opportunity to provide pharmacological benefits to my patients… and give my patients better outcomes with providing sort of high level of care” P11 (non-endorsed; willing to become endorsed; private sector; metro based)
Competence and autonomy were commonly reported as an important facilitator by those either already endorsed or currently in training, suggesting this is a motivation that empowered action.
“My main motivation was really because I was doing a lot of ingrown toenail procedures and one of the more common adverse events is infection, postoperative infection… you can only manage it so far.” P13 (endorsed pod; experience in public and private sectors; metro based)
A desire for autonomy was particularly strong in those based in rural environments where participants observed poor access for patients to general practitioners (GPs).
“…the main reason I guess [to become endorsed] is that because we are rural... We have very few doctors in the last year or in the last 18 months, there's been a shortage in our area……..I feel that if I'm in a place that I can prescribe antibiotics straight away, that would be more beneficial for my patients” P12 (non-endorsed; willing to become endorsed; private sector; regional/rural and metro based)
Individuals who already had a level of competence with pharmacological knowledge recognised the advantage of this prior knowledge and expressed a desire to capitalise on this.
“… Also my background in pharmacy did help a lot. I was familiar with the majority of drug names, even those that aren't on our list and how pharmacists work, that helped a lot.” P4 (endorsed pod; private sector; metro based)
An approved qualification in podiatric therapeutics is now incorporated into most undergraduate courses. One participant demonstrated that this study could provide a sense of competence that may motivate further skill development.
“because I'm more fresh (sic) out of university, I'd like to do it sort of sooner rather than later so that my knowledge that I gained through university, won't be lost.” P11 (non-endorsed; willing to become endorsed; private sector; metro based)
Even in a participant unwilling to become endorsed, increased pharmacological knowledge was recognised to provide valuable insight in patient care.
….. I wasn't that keen on pharmacology at uni, but I could definitely see the advantages of it once I got out in practice...” P9 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
Some participants believed that becoming an endorsed prescriber may improve job security.
“…I thought professionally it would make me a more desirable job applicant…….it increases job security, having that extra skill.” P2 (completed training; public sector; metro based)
Similarly, one participant expressed a desire not to be left behind the skill progression in the profession.
“…I guess I decided to do it because I can see that that's the direction the podiatric discipline is heading and I don't want to be left behind, so I assume that eventually students will graduate with the ability to prescribe and that would put me at a disadvantage in the future.” P5 (early stage training; private sector; metro based)
On the other hand, some podiatrists demonstrated an innate conservatism in professional identity and boundaries. These podiatrists believed they could be successful without becoming endorsed or they practiced in an area of podiatry that they perceived did not require an increased scope of practice provided by becoming an endorsed prescriber.
“I don't think people really see the benefit because you can be a successful podiatrist without the need for having endorsed capabilities. I also think that some podiatrists have chosen a different path, so they're steering away from a medical-based podiatrist and heading more towards a sports podiatrist or biomechanics, in which case it's also not necessarily required to have the endorsed prescribing.” P5 (early stage training; private sector; metro based)
“…When I first graduated from university, I went straight to aged care. So, in the aged care sector, it was all nursing homes and home visits. So there was no need to study for prescribing rights…” P8 (non-endorsed; neutral; private sector; metro based)
Further to this, one participant reflected that having access to scheduled medicines may decrease competence and result in a deterioration of the level of skill in the profession. This participant exposed a deep respect for traditional podiatry skills and suggested they would rather avoid the temptation of access to scheduled medicines.
“a problem with being a prescriber is much like a lot of general practices…prescribe drugs become the first avenue of action, instead of the last avenue of action. So I have my concerns about that process as well, that we lose our ability to work without them, or it becomes easy to work with them…” P7 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
Theme 2: Social and workplace influences
Analysis of the data revealed both social and workplace culture and beliefs also influenced engagement, behaviours, and values.
The low numbers of podiatrists that hold endorsement was a prominent barrier in many ways including creating the perception that it is not a ‘necessary’ skill required to practice.
“… I think when more podiatrists do it [prescribing]…At the moment there's not many, but... If it becomes a necessity and everyone needs to get it, then it might entice more people to train for it.” P8 (non-endorsed; neutral; private sector; metro based)
Whereas, when prescribers were visible such as working with someone who was an endorsed prescriber, it exposed podiatrists to the benefits of having this skill.
“I think having an endorsed prescriber at my workplace full time as my main supervisor was a very big help….. that would have been the primary one [facilitator]” P4 (endorsed pod; private sector; metro based)
Further, having a supportive workplace that provided opportunity and flexibility was a commonly reported facilitator.
“…I had a very supportive boss that allowed me to go and sit in with all these other disciplines….and gave me flexibility around work time to do those extra activities as well.” P2 (completed training; public sector; metro based)
Mentors play a pivotal role in the process to gaining endorsement and access to one was an important facilitator. However, for many identifying a mentor was a barrier. One participant highlighted that access to mentors is a symptom of the lack of a formalised structure in the current pathway to endorsement.
“…The next big one is the formulary that we have. And there's not enough opportunities…for clinical training in a closely mentored environment…If you don't have a formalised sort of residency type or intern structure that people can plug in to, they feel kind of nervous about doing it... The difficult bit is that clinical competency and way you can get it developed. That's not very well addressed to this at this stage…” P1 (endorsed podiatric surgeon; private sector; metro based)
Access to opportunities to undertake the supervised practice component of the training was widely reflected on. Like mentor access, easy access through the workplace, was also a facilitator.
“… because I was working in the public sector, I had access to rotations with other health practitioners really easily. So, I could go and sit in on endocrinologists or rheumatologists or contact pharmacists or vascular surgeons. I had all of these disciplines that I already had strong relationships with, so I could just go and…spend some time with them to develop these cases. I think that was a really key factor for me…” P13 (endorsed podiatrist; experience in public and private sectors)
However, a lack of access to these opportunities was recognised by participants as a barrier for those outside of the hospital system in fulfilling the required supervised practice across broad areas of medicine.
“…I think the biggest barrier to the process and starting it, is finding someone in the first place. And then also, because I work in XXXXX (a large public sector organisation), I'm covered by professional indemnity insurance through XXXXX (a large public sector organisation) and if you are a private podiatrist and wanted to observe at a hospital, it becomes very difficult because of mandatory training, confidentiality, hospital insurance…..I think that's a huge barrier for other podiatrists.” P2 (completed training; public sector; metro based)
There were also examples of how both social and workplace networks can undermine people’s sense of volition and initiative to become an endorsed prescriber.
“…with our podiatry peers, you don't really talk about it much. So, I guess it's not something that's big on our agenda at the moment, or has been since I've graduated, I only know one person that's got prescribing rights in my podiatry peers.” P8 (non-endorsed; neutral; private sector; metro based)
Additionally, professional networks can provide easy access to alternate prescribers, negating the need to become endorsed.
“…I have good relationships with the local general practitioners and so most things that need prescribing can be easily attained through that relationship…” P7 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
Participants also reflected that some work environments may be more supportive of the endorsement process. Some in private practice thought those in the public sector had more support to complete endorsement, while others thought the easy access to other prescribers may discourage public sector podiatrists for becoming endorsed.
“I think in the public sector at the moment, you have a lot more time and then seem to have a lot more allocation for continued education and development, so now they can allocate their time easier……They've paid time to do these sorts of things…” P7 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
“…I probably would be discouraged in public [sector] in that…you have access to other people who can prescribe so…… So they may not see that as a number one priority…” P9 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
One private practice podiatrist thought that being an endorsed prescriber would be more useful in private than in public practice.
In private, I can sort of, I can see that it would be of more benefit … P9 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
In addition to limited mentoring and supervised practice opportunities, the small number of endorsed prescribers may result in a lack of awareness on a public level of the scope of practice of modern podiatry. One participant commented on a stigma of podiatrists being ‘toenail cutters’ and therefore not the first point of contact for more complex cases that may require the prescription of scheduled medicines.
“So, at the moment there's not many podiatrists that do it and I guess it's not something that the public is aware of... if you talk about podiatrists, you assume…general nail care. And most clients think you only do that... That's already like a stigma with podiatry. And the public not having knowledge that we can prescribe... We're not the first point of contact for anything related.” P8 (non-endorsed; neutral; private sector; metro based)
Being in rural locations offered many barriers including: access to mentors, time away from work, professional isolation, staffing, and internet access.
“But as far as the logistics of studying these sort of things, we have a limit of where I live on a farm, we have limited internet access, so you know, online lectures and that sort of stuff would be a real burden for that process. So I travel around a lot, so there's a lot of time spent in cars and stuff, which take away time from them [family] as well as work. So yeah, there's lots of impediments to rural practice and my situation” P7 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
Theme 3: Extrinsic motivators
Time was a particularly notable barrier for private sector podiatrists in the rural setting as their workday involves a considerable amount of travel time which is often in addition to their regular work hours, as well as for non-endorsed podiatrists.
“Well it's probably just not worth it from the amount of time involved for this. Maybe three to six months to treat would then maybe becomes more realistic to do.” P10 (non-endorsed; neutral; private sector; metro based)
Hospital based podiatrists who were currently undertaking training recognised the advantage they had of time not being a barrier for them.
“…I was already doing this work [in hospitals] and already gaining hours and I didn't have to take time off of work to get hours…” P2 (completed training; public sector; metro based)
Personal priorities and stage of life and career also seem to play an influencing role as participants reported weighing up a number of personal life factors.
“it depends on your stage of life as well. So, if you have commitments, family, children, a mortgage or so on so forth, that might also deter whether you go for it or not.” P8 (non-endorsed; neutral; private sector; metro based).
One participant reflected that as they were at the start of their career, they would like to settle in before undertaking further training. Conversely some commented that as they were at the end of their careers, they had already done other advanced study and had other interests they would rather invest their time in.
Participants were not only concerned about their own time, but that it would be more time efficient and convenient for the patient if they could prescribe directly rather than having to refer patient to their GP for an additional appointment.
“…the convenience of it, that it would just make probably life a little bit easier for us and also for our patients. That sometimes it's quite annoying to them that they come and see me, and I say, ‘Oh, you need this and this, but I can't actually prescribe it to you. You need to now go and make an appointment and see your GP.’ And they just can't always get to see their GP on today or get in touch with their usual doctor.” P3 (in-training; public sector; metro based).
The barriers of time and stage of life were compounded by the financial costs involved in training, particularly those who had to complete an approved podiatric therapeutics course.
“There is also the financial…I believe it's about $5,000 to do that course… …..” P6 (non-endorsed; willing to become endorsed; private sector; metro based)
“…because I've just moved house and getting a new mortgage and everything costs is a bit more prohibitive to me at the moment…” P9 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
Interestingly, both the cost of training as well as the lack of financial incentives to become endorsed was reported as a disincentive by a podiatric surgeon who was endorsed, and therefore had considerable insight into the true financial and time commitment.
“… there's a financial disadvantage…..if it's not going to make a massive difference to your podiatry practice… why spend the time and all the money to train yourself into something that's going to make very little difference to your day to day practice.” P1 (endorsed podiatric surgeon; private sector; metro based)
The lack of access to Pharmaceutical Benefits Scheme (PBS) funding for podiatrists meant their patients do not qualify for existing subsidies and must pay full price for medications prescribed by a podiatrist. Podiatry are the only non-medical endorsed prescribers not covered by the PBS. The additional costs to patients were a barrier for some participants, as was the difficulty this created for funding hospital inpatients.
“...the lack of PBS funding means it's difficult for podiatrists to prescribe, even if they're endorsed because the pharmacist are looking at them going, ‘Well, you don't have to prescriber number, so how can you prescribe?’ The pharmacy people in the hospital departments don't know where to get the funding for. Somebody's got to pay for the drugs. If you work in a hospital or somewhere else, where does the money come from? So, the lack of PBS is a major concern” P1 (endorsed podiatric surgeon; private sector; metro based)
Some participants thought being and endorsed prescriber could be recognised with higher private or public health rebates. However, the desire for autonomy outweighed the finance disincentives for some.
“…so I could say that if you're an endorsed provider you get…better Medicare rebate where you can get rebates and things like that…” P9 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
“There’s no financial gain… The gain is in a more complete management portfolio…” P1 (endorsed podiatric surgeon; private sector; metro based)
Another interesting finding from this research was the lack of awareness of the current training requirements.
“Probably my slight lack of understanding is probably also just causing me not to make a concrete plan to move forward.” P6 (non-endorsed; willing to become endorsed; private sector; metro based)
This was demonstrated by some participants who were unaware that recent changes to Pathway B for endorsement have decreased the number of case studies required to 15.
“… if it's a hundred cases then that's going to take a long period of time…I'd probably think it might not be worth becoming endorsed. If it was more, 10 to 12 cases, but then it might become more feasible to achieve that in a relatively short period of time. “P10 (non-endorsed; neutral; private sector; metro based)
Some participants also provided suggestions on changes as means of ameliorating some of the barriers reported previously. One participant reflected that an increase in community acceptance, PBS funding, or numbers of endorsed prescribers would occur in the near future and may drive increased uptake of endorsement.
“…I think that in the next five years there'll be exponential growth…it grows because it's got more cultural acceptance in the community, PBS funding, more people are out there practicing, [and] train people. I think that will change” P1 (endorsed podiatric surgeon; private sector; metro based)
Additionally, there was support for the approved qualification in podiatric therapeutics and all requirements for the endorsement qualification to become incorporated into the undergraduate course.
“I think it's a positive thing and I think it should probably be in the Uni course as much as it can be before a person graduates ....” P9 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)
Further to this, one participant reflected that unexpected global health events, such as the SARS-CoV-2 (COVID-19) pandemic may facilitate his motivation to become an endorsed prescriber.
“I think it's something like what's happening at the moment [COVID-19], like if things came along or conditions came along that needed to be prescribed drugs, then maybe that would convince me…” P7 (non-endorsed; unwilling to become endorsed; private sector; regional/rural based)