Demographic data

A total of 20 pharmacists participated in this study, representing a diverse range of backgrounds and experiences within general practice settings in England. All participating pharmacists work in a general practice setting with independent prescriber status. The participants included 9 males and 11 females, with ages ranging from 26 to 52 years. This range of demographics provided a broad perspective on the prescribing practices and challenges faced by pharmacists in managing AF. Participant demographic data is shown in Table 1. Interviews lasted 32–64 min (mean 48 min), were audio-recorded, and transcribed verbatim using the platform’s transcription function. Transcripts were returned to participants for checking; minor corrections were made where requested.

Table 1 Demographics of pharmacists included in the study

Analysis of the interview data identified four main themes, confidence and experience in prescribing; perceived role and responsibilities; barriers to effective prescribing; and strategies for effective prescribing, each with corresponding subthemes. These encompassed variations in prescribing confidence, the diversity and clarity of pharmacist roles, practical challenges such as limited access to records and high workload, and the importance of ongoing professional development, decision support, and peer collaboration. The mapping of these themes and subthemes to relevant TDF domains is visually summarised in Fig. 1, demonstrating the multifaceted influences on pharmacist-led AF management.

Fig. 1

Summary of the four key themes and subthemes emerging from the qualitative analysis, mapped to relevant Theoretical Domains Framework (TDF) domains

In addition, Table 2 summarises the specific facilitators and barriers that emerged from the interviews, offering a clear comparison of the main factors that either supported or hindered effective prescribing practices among general practice pharmacists. The table presents these facilitators and barriers alongside their corresponding TDF domains, highlighting how factors such as access to training, role clarity, and peer support contributed positively, while challenges like limited guideline familiarity, time constraints, and lack of confidence posed significant obstacles to optimal pharmacist-led care.

Table 2 Key facilitators and barriers identified from pharmacist interviews mapped against the most relevant TDF domainsTheme 1 – Confidence and experience in prescribing

Confidence and experience in prescribing medications for AF emerged as a key theme in this study. The pharmacists' levels of confidence and experience were closely linked to several domains of the TDF, particularly knowledge, skills, beliefs about capabilities, and social influences.

Subtheme 1: High confidence due to extensive experience (mapped to TDF domains: skills, beliefs about capabilities)

Pharmacists with extensive experience in managing AF patients demonstrated a high level of confidence in prescribing, a belief in their abilities and well-developed skills which led to their confidence in managing AF patients and prescribing for them. This was evident in the responses of Pharmacist A, who, with 18 years of experience, described their confidence in prescribing:

"I’ve had quite a lot of experience prescribing medications for patients, mainly focusing around AF and DOACs. I feel quite confident in being able to initiate the appropriate treatment for the patient." (P1).

In contrast, another participant described hesitancy when prescribing for AF, particularly around initiating DOACs in complex cases.

“I feel less confident initiating DOACs in complex cases, where multimorbidity and competing risks make decisions challenging.” (P7).

Subtheme 2: Moderate confidence with support from guidelines (mapped to TDF domains: knowledge, skills, beliefs about capabilities)

Pharmacists who reported moderate confidence often relied on their knowledge of clinical guidelines and the use of decision support tools to reinforce and support their prescribing decisions. This reliance on external resources helped bridge the gap between their knowledge and their belief in their capabilities.

"I am fairly confident in prescribing for AF, but I always make sure to follow the NICE guidelines closely and use decision support tools to guide my decisions." (P9).

Subtheme 3: Acting within competence through support seeking (mapped to TDF domains: beliefs about capabilities, social influences)

Pharmacists with less experience in AF management described feelings of uncertainty when making prescribing decisions. However, rather than being solely a matter of “low confidence,” these accounts often reflected appropriate professional judgement, recognising the limits of their current knowledge and seeking advice from more experienced colleagues. This illustrates how pharmacists managed risk by acting within their competence:

"My experience in prescribing for AF is limited, and I often feel uncertain… I usually ask for advice from more experienced colleagues before making decisions." (P5).

Another participant described navigating uncertainty by pairing guideline use with targeted case discussion:

“I start with NICE and the PCN checklist to cover essentials, then confirm any uncertainties with the GP lead.” (P8).

This behaviour highlights an important dimension of safe practice: although less experienced pharmacists may not independently initiate treatment, they are able to safeguard patient care by drawing on social support and available expertise until their competence develops.

Theme 2: Perceived role and responsibilities

All interviewees discussed at length the emergent second major theme. This theme focuses on how pharmacists perceive their roles and responsibilities in managing AF. Pharmacist perceptions of their roles varied, with some viewing themselves as central and proactive in the management of AF, while others saw their role as more supportive or adjunctive to other, more senior, healthcare professionals in their respective general practices.

Subtheme 1: Central role in medicines optimisation (mapped to TDF domains: social/professional role and identity, environmental context and resources)

Many pharmacists described a central role in medicines optimisation, aiming for guideline-concordant, target-driven anticoagulation delivered through longitudinal monitoring and review to maintain safety and effectiveness.

As one interviewee explained,

"My role as a pharmacist generally involves managing the medication side of things… Ensuring that the patient is appropriately anticoagulated and that their treatment is being monitored regularly." (P1).

Many described the importance of ongoing medication review to ensure appropriateness of therapy,

“…part of the role is make sure to review and adjust treatment plans based on the individual patient in front of me, which is evolving over time, taking into account other health conditions and e.g. renal function as they age.” (P15).

Subtheme 2: Supportive role in a multidisciplinary team (mapped to TDF domains: social/professional role and identity, social influences)

Many interviewees viewed their role as more supportive, working in collaboration with the wider practice teams of doctors and other healthcare professionals to manage AF. This perspective was often shaped by the collaborative nature of their work environment, where decisions are made jointly. Pharmacist C reflected this view:

"I see my role as supporting the healthcare team, helping to ensure that patients are on the correct medication and understand their treatment, while working closely with the rest of the team to make changes to therapy." (P3)

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This coordination focus was echoed by mid-career prescribers, highlighting routine collaboration with GP leads within MDT pathways to maintain coherent, patient-centred anticoagulation plans.

“I review anticoagulation, explain options to patients, then align any changes with the GP lead to keep plans consistent.” (P11).

Subtheme 3: Role boundaries and identity challenges (mapped to TDF domains: social/professional role, identity and social influences)

Some pharmacists described challenges around role boundaries and professional identity, particularly when responsibilities for initiation versus monitoring were not explicitly defined within the practice. This sometimes led to uncertainty about responsibilities or hesitancy in making independent prescribing decisions. In addition to intra-team boundaries, several pharmacists perceived that some patients sought GP confirmation before accepting anticoagulation changes, reflecting variable recognition of pharmacist prescribing role and credibility: this occasionally delayed initiation despite agreement within the team.

As one interviewee explained,

"There are times when it’s unclear whether I should be making the prescribing decision or if it’s better left to the GP… It can be challenging to work around these role boundaries." (P20).

An experienced pharmacist linked hesitation to unclear responsibilities in high-risk scenarios, citing role ambiguity during DOAC initiation.

“I sometimes struggle to initiate DOACs in complex multimorbidity; role boundaries aren’t always clear in critical cases.” (P7)

Subtheme 4: Patient perceptions and trust in pharmacists (mapped to TDF domains: social influences, professional role and identity)

A few participants noted situations where patients were reluctant to accept their prescribing advice until it was confirmed by a GP. This highlighted not only the role boundaries within the healthcare team but also the influence of patient perceptions on pharmacist ability to enact their prescribing role.

Less frequently, some interviewees described situations to persuade patients to commence oral anticoagulation therapy,

“I tried to convince them of the alternatives to warfarin that we have, explaining that it’s readily available, would not require the same regular monitoring at the hospital, it is as good, but sometimes they’re insisting on discussing this with the healthcare professional they regularly see at the warfarin clinic.” (P17).

“I recommended a patient start on a DOAC, gave them the options and discussed the differences between them. She seemed reluctant and said she would have a think about it. Later that week, the GP let me know she had made an appointment with him and asked about the DOACs and was happy for it to started by the doctor.” (P19).

This suggests that while pharmacists may be clinically competent, patient trust and acceptance of their role can act as an additional barrier to effective prescribing.

Theme 3: Barriers to effective prescribing

Barriers to effective prescribing emerged as a core theme. Interviewees identified numerous challenges encountered that may hinder the effective management of AF patients.

Subtheme 1: Limited access to patient records (mapped to TDF domain: environmental context and resources)

A recurring barrier mentioned by pharmacists was the difficulty in accessing comprehensive patient records, which are crucial for making informed prescribing decisions. This lack of access often led to uncertainty and hesitation in prescribing, as highlighted by participant 4:

"It’s really challenging when you don’t have full access to patient records as they patients have their blood tests and monitoring done elsewhere e.g. in the hospital and you do not always get to see the results… You’re making decisions with incomplete information, which isn’t ideal when prescribing anticoagulants and trying to review medications." (P4).

Another participant, expressed this concern, noting how this barrier often delayed their decision-making process:

"Sometimes, I have to wait for test results or information from other providers, which can delay the starting of treatment as often the diagnosis of AF is done at the hospital. This can be frustrating and can affect patient outcomes." (P12).

Subtheme 2: Inadequate training and experience in AF management (mapped to TDF domains: knowledge, skills)

A number of interviewees expressed that their training and experience in AF management were inadequate.

"I feel like my training didn’t fully prepare me for the complexities of AF management… There’s a lot I still need to learn, and that makes me hesitant to make clinical decisions." (P14).

"I often find myself requesting advice from the GP when it comes to making final decisions… I just don’t feel fully prepared to take on that responsibility yet." (P3).

Subtheme 3: Time constraints and workload pressures (mapped to TDF domain: environmental context and resources)

Time constraints and high workload were also described as significant barriers that impacted pharmacists' ability to prescribe effectively.

"There’s just not enough time to really dive into each patient’s case… You end up making quick decisions, which isn’t always the best approach, especially with something as critical as AF." (P2).

Similarly, interviewees described how the workload affected their ability to follow up with patients:

"I struggle to keep up with all the follow-ups, and that’s crucial for AF patients. The workload just doesn’t allow for it in and amongst other tasks that have to be done." (P16).

“Because of admin and same-day requests, I sometimes cannot perform proactive reviews, so anticoagulation reviews slip to next week.” (P13).

Theme 4: Strategies for effective prescribing

Pharmacists employed various strategies to stay updated on the latest guidelines and make informed prescribing decisions.

Subtheme 1: Continuous professional development and education (mapped to TDF domain: knowledge)

A common approach among pharmacists was engaging in continuous professional development (CPD) activities, such as attending workshops, conferences and training sessions. These opportunities allowed them to stay informed about the latest guidelines and emerging treatments.

"I make it a point to attend relevant CPD sessions and conferences whenever possible. It’s crucial to stay on top of the latest guidelines and treatments for AF." (P1).

"The CPD courses I attend, especially those focused on cardiovascular health, are incredibly useful. They help me stay confident in my prescribing choices." (P4).

“A recent anticoagulation webinar changed my approach, now I check renal trends first and document bleed risk more systematically.” (P14).

Subtheme 2: Use of decision support tools and clinical guidelines (mapped to TDF domains: memory, attention, and decision processes, skills)

Many interviewees also relied heavily on decision support tools and clinical guidelines to inform their prescribing decisions. These resources provided quick access to evidence-based recommendations, helping pharmacists navigate complex cases with confidence.

"I always use decision support tools and make sure to have the latest clinical guidelines on hand. They’re very useful when it comes to making safe prescribing decisions." (P9).

“The EHR prompts, and our anticoagulation checklist remind me about renal function, interactions, and bleeding risk so I don’t miss steps.” (P18).

Subtheme 3: Peer review and professional networks (mapped to TDF domains: social influences and skills)

Several interviewees emphasised the importance of peer consultation and review and professional networks as crucial elements of their approach to staying informed and making well-informed decisions, alongside formal tools and education.

"I often consult with my colleagues, especially when I’m unsure about a case. These discussions are invaluable for gaining new insights and ensuring I’m making the best decisions for my patients." (P2).

One participant also highlighted the role of professional networks in staying informed:

"Being part of a professional network allows me to stay in the loop with the latest practices in AF management. It’s a great way to learn from others’ experiences and discuss particular cases." (P6).