Independent Non-medical Prescribing Research Articles

Patient and Public Involvement in Research Evaluating Integrated Care for People Experiencing Homelessness: Findings From the PHOENIx Community Pharmacy Pilot Randomised-Controlled Trial.

There is a paucity of research on and a limited understanding of patient and public involvement (PPI) in the context of research in homelessness and, in particular, direct involvement of people with lived and living experience of homelessness (PEH) as expert advisors. We aim to report on outcomes and reflections from lived experience advisory panel (LEAP) meetings and PPI activities, held throughout the study lifecycle of a pilot randomised-controlled trial (RCT) focused on evaluating integrated health and practical support for PEH. Community Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx (PHOENIx Community Pharmacy RCT) is an integrated health and social care intervention for people experiencing homelessness who present to community pharmacy. Intervention includes weekly support from a pharmacist prescriber and a third sector support worker for up to 6 months. PPI activities undertaken throughout the study were documented, including outcomes of LEAP meetings. Outcome reporting followed Guidance for Reporting Involvement of Patients and the Public 2 Short Form (GRIPP2-SF). In total, 17 members were recruited into the LEAP; six meetings (three in two study sites) were held. PPI input was also received through representation from homelessness third sector organisation staff as study co-applicants and core membership in the trial steering committee. Together, the PPI activities helped shape the study proposal, design of study materials, data analysis and dissemination materials. LEAP panel members offered valuable input via their experience and expertise into the delivery and refinement of interventions. Although longitudinal input was received from some LEAP members, ensuring repeat attendance in the pre-planned meetings was challenging. People who face social exclusion and marginalisation can provide highly valuable input as equal partners in co-design and delivery of interventions seeking to improve their health and well-being. Fluid membership and flexible methods of seeking and incorporating advice can offer pragmatic approaches to minimising barriers to continued involvement in research. This study reports findings and learning relevant to involvement of people with lived and living experience of homelessness as advisors in a research study. It is important for researchers to offer fluid memberships and use diverse methods to receive input from lived experience members, as traditional PPI methodology may be insufficient to ensure inclusivity. Staff and volunteers from third sector organisations were important PPI partners who bring their experience based on frontline service provision, often as the first port of call for people experiencing severe and multiple disadvantage. ISRCTN88146807.

Perspectives of people experiencing homelessness with recent non-fatal street drug overdose on the Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx) intervention.

In Scotland, a third of all deaths of people experiencing homelessness (PExH) are street-drug-related, and less than half of their multiple physical- and mental health conditions are treated. New, holistic interventions are required to address these health inequalities. PHOENIx (Pharmacist Homeless Outreach Engagement and Non-medical Independent prescribing Rx) is delivered on outreach by National Health Service (NHS) pharmacist independent prescribers in partnership with third sector homelessness charity workers. We describe participant's perspectives of PHOENIx. This study aims to understand experiences of the PHOENIx intervention by participants recruited into the active arm of a pilot randomised controlled trial (RCT). Semi-structured in-person interviews explored participants' evaluation of the intervention. In this study, the four components (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalisation Process Theory (NPT) framework underpinned data collection and analyses. We identified four themes that were interpreted within the NPT framework that describe participant evaluation of the PHOENIx intervention: differentiating the intervention from usual care (coherence), embedding connection and consistency in practice (cognitive participation), implementation of practical and emotional operational work (collective action), and lack of power and a commitment to long-term support (reflexive monitoring). Participants successfully engaged with the intervention. Facilitators for participant motivation included the relationship-based work created by the PHOENIx team. This included operational work to fulfil both the practical and emotional needs of participants. Barriers included concern regarding power imbalances within the sector, a lack of long-term support and the impact of the intervention concluding. Findings identify and describe participants' evaluations of the PHOENIx intervention. NPT is a theoretical framework facilitating understanding of experiences, highlighting both facilitators and barriers to sustained engagement and investment. Our findings inform future developments regarding a subsequent definitive RCT of PHOENIx, despite challenges brought about by challenging micro and macro-economic and political landscapes.

Nurses' perceived barriers and facilitators to the implementation of nurse prescribing: Delphi study and focus group.

To obtain consensus on barriers and facilitators to nurse prescribing following its recent introduction in Spain. A three round online Delphi survey and focus group. An exploratory method was used with three consecutive rounds of questionnaires based on anonymity and feedback, and a focus group. The study was carried out with primary care, specialized care, socio-health care and manager nurses. On the basis of the Delphi study that was conducted, a list of 15 barriers and 18 facilitators of nurse prescribing was obtained. However, no general consensus was found with respect to the prioritization of these barriers/facilitators. The analysis of the results of the focus group confirmed the information obtained from the Delphi study. The main barriers highlighted were dependence on the figure of the physician, insufficient training in pharmacology, a lack of institutional support and the limited list of products that could be prescribed. The key facilitators were academic knowledge and ongoing training and education, independence in the functions and responsibilities of the nursing profession, adaptation to new roles and autonomy in the case of chronic care processes. Nurses were generally positive about the introduction of nurse prescribing. The commitment of nurses to training and their accreditation as prescribers (internal forces) and health policy and nursing management (external forces) play a fundamental role in supporting the basis of nurse prescribing and ensuring that it is developed with the identified support resources, such as staff training and the provision of the materials necessary for its proper implementation, all with the aim of guaranteeing quality healthcare. Strong models of nurse prescribing are being considered globally to address population needs. The results can help the future implementation of non-medical independent prescribing and provide guidance to the government and society on the interventions that can be used to consolidate it. What problem did the study address? By 2027, the world's population will receive more than 4.5 trillion doses of medicine each year. However, the WHO estimates a projected shortfall of 10 million health workers by 2030. Inadequacies with traditional physician-led care systems mean that new approaches are imperative to maintain patient access to prescription medicines, with NP being a key element in this regard. In Catalonia (Spain), the accreditation process for nurses as prescribers was implemented in 2021. It is therefore of vital importance to question and consult the nurses themselves, the main promoters of the process, to find out their perceptions and thus be able to take them into consideration in the implementation process. What were the main findings? A total of 15 barriers and 17 facilitators were identified. The main perceived barriers are dependence on the figure of the physician, insufficient training in pharmacology during undergraduate studies and a lack of institutional support. The main perceived facilitators are academic knowledge and ongoing education and training, independence in nursing functions and responsibilities, and adaptation to new roles and tasks. Where and on whom will the research have an impact? These results can contribute to improving NP implementation in Spain and serve as a reference for other countries, especially where NP education and training have only recently been instigated or are in the planning process. Standards for reporting qualitative research: a synthesis of recommendations. SRQR. No patient or public contribution.

Protocol for a pilot randomised controlled trial to evaluate integrated support from pharmacist independent prescriber and third sector worker for people experiencing homelessness: the PHOENIx community pharmacy study

BackgroundPeople experiencing homelessness (PEH) have complex health and social care needs and most die in their early 40 s. PEH frequently use community pharmacies; however, evaluation of the delivery of structured, integrated, holistic health and social care intervention has not been previously undertaken in community pharmacies for PEH. PHOENIx (Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx) has been delivered and tested in Glasgow, Scotland, by NHS pharmacist independent prescribers and third sector homelessness support workers offering health and social care intervention in low threshold homeless drop-in venues, emergency accommodation and emergency departments, to PEH. Building on this work, this study aims to test recruitment, retention, intervention adherence and fidelity of community pharmacy-based PHOENIx intervention.MethodsRandomised, multi-centre, open, parallel-group external pilot trial. A total of 100 PEH aged 18 years and over will be recruited from community pharmacies in Glasgow and Birmingham. PHOENIx intervention includes structured assessment in the community pharmacy of health, housing, benefits and activities, in addition to usual care, through weekly visits lasting up to six months. A primary outcome is whether to proceed to a definitive trial based on pre-specified progression criteria. Secondary outcomes include drug/alcohol treatment uptake and treatment retention; overdose rates; mortality and time to death; prison/criminal justice encounters; healthcare utilisation; housing tenure; patient-reported measures and intervention acceptability. Analysis will include descriptive statistics of recruitment and retention rates. Process evaluation will be conducted using Normalisation Process Theory. Health, social care and personal resource use data will be identified, measured and valued.DiscussionIf the findings of this pilot study suggest progression to a definitive trial, and if the definitive trial offers positive outcomes, it is intended that PHOENIx will be a publicly funded free-to-access service in community pharmacy for PEH. The study results will be shared with wider stakeholders and patients in addition to dissemination through medical journals and scientific conferences.Trial registrationInternational Clinical Trial Registration ISRCTN88146807.Approved protocol version 2.0 dated July 19, 2022.

Pharmacist and Homeless Outreach Engagement and Non-medical Independent prescribing Rx (PHOENIx): a study protocol for a pilot randomised controlled trial

IntroductionThe number of people experiencing homelessness (PEH) is increasing worldwide. Systematic reviews show high levels of multimorbidity and mortality. Integrated health and social care outreach interventions may improve outcomes. No...

The influence of non-medical prescribers on antimicrobial stewardship: a national evaluation of the impact of the COVID-19 pandemic on the prescribing of antibiotics by non-medical prescribers in England in 2020 (part 2)

Background Part one of this study identified that prescribing behaviours during 2020 differed significantly from 2016-2021. Part 2, presented here, covers a more detailed analysis of the impact of the early part of the COVID-19 pandemic is presented here. Aims To describe patterns in community prescribed and dispensed antibiotic volumes attributable to non-medical prescribers during 2020 compared to the previous 4 years and identify any changes of behaviour during this period and their impact on antimicrobial stewardship. Methods An analysis of retrospective non-medical prescribers' prescribing data was performed to determine the numbers of independent non-medical prescribers and the patterns of prescribed community dispensed antibiotic volumes between 2016-2021. The 2020 data were then compared to the data from previous years. Findings The total amount of dispensed non-medical prescribers antibiotic prescription items per 100000 population dropped by 12% in 2020 compared to 2019, driven predominantly by reductions in nurse prescribing. However, high-risk antibiotic prescribing rose from 5.3% of antibiotics prescribed in 2019 to 6.4% in 2020. Seasonal patterns of antibiotic prescribing differed in 2020, with significant reductions in prescribing of antibiotics normally associated with treating LRTI from the first lockdown in March 2020. Conclusions The COVID-19 pandemic forced rapid changes in practice, including increased remote working, which created a challenging prescribing environment that adversely affected the high-risk antibiotic prescribing behaviour of non-medical prescribers more than it affected their medical colleagues. There were unusually low levels of prescribing for respiratory tract infections over the last quarter of 2020 which, although likely multifactorial, may indicate over-prescribing for self-limiting viral infections in previous years. More research is needed to establish ongoing prescribing trends and patient outcomes, and how antimicrobial stewardship programmes and training can be better targeted to support prescribers to address quality and safety issues arising from changing modes of practice.

The influence of non-medical prescribers on antimicrobial stewardship: a national evaluation of the prescribing of antibiotics by non-medical prescribers in England from 2016 to 2021 (part 1)

Background Non-medical prescriber numbers have increased rapidly over the last 10 years, with increasingly diverse roles and backgrounds. Previous evaluations of their antibiotic prescribing demonstrated it was generally of a high quality and guideline-driven, but recent evidence is lacking and the data are not easily accessible. Aims To describe changes in the non-medical prescriber population and patterns in dispensed antibiotic volumes between 2016–2021, highlighting evidence of good antimicrobial stewardship and where further interventions may be required. Methods An analysis of retrospective non-medical prescriber prescribing data was performed, to determine the numbers of independent non-medical prescribers and the patterns of prescribed community-dispensed antibiotics in England between 2016–2021. Findings Between 2016–2021, it was found that independent non-medical prescriber numbers in England rose by 54%. Whilst they remain predominantly nurses (76%), the numbers of pharmacists and allied health professionals have increased. Non-medical prescribers were responsible for 10.6% of all dispensed antibiotic items prescribed in primary care in England. However, the proportion of dispensed antibiotic items prescribed by these non-medical prescribers reduced by over 50%. Prescribing in 2020 differed from previous years, with increased high-risk antibiotic prescribing. Conclusion The quality of prescribing generally appears good and in accordance with national guidelines and principles of good antimicrobial stewardship. The 2020 COVID-19 pandemic prompted changes in antibiotic prescribing behaviour.

A multi-site prospective, observational study of physiotherapist independent prescribing activity across musculoskeletal clinics in the United Kingdom

ObjectiveTo establish how advanced practice physiotherapists in the UK working in the musculoskeletal specialty are utilising their independent non-medical prescribing skills. DesignMulti-site, prospective, descriptive observational study. Ethics reference No: ERN_19–0994). MethodThe study was conducted by seven advanced practitioners, across seven clinical sites representative of advanced musculoskeletal practice in the UK, between 1st October 2019–March 31, 2020. Advanced physiotherapy practitioner independent prescribers working in a variety of musculoskeletal specialty areas collected data across 5 contexts of musculoskeletal clinical service: first contact practice, primary care, community triage, secondary care orthopaedics, secondary care rheumatology and private practice. Quantitative data were analysed descriptively with qualitative data analysed/synthesised via thematic analysis. ResultsPrescribing activity data for n = 2470 patients were collected. Prescribing activity was highest for the treatment of nociceptive pain (51.3%) and inflammation (39.6%). Most prescribing activity occurred in the first 2–6 weeks (34.1%) following onset of condition. Medicines optimisation accounted for most of prescribing activity (18.1%), followed by over-the-counter medication recommendation (15.5%). De-prescribing accounted for 10.8% of all prescribing activity recorded. Qualitative data were synthesised into 4 themes: multimodal physiotherapeutic approach, joint decision making and patient choice, working with complexity, and legal and regulatory restriction. ConclusionsPhysiotherapist independent prescribing was used within all health sectors in conjunction with advanced skills in musculoskeletal physiotherapy as part of a multimodal physiotherapeutic approach. Prescribing activity was dictated by the clinicians' clinical reasoning and use of joint decision-making. Prescribing activity for acute back and neuropathic radicular pain was limited secondary to recent reclassification of gabapentin and pregabalin.

Barriers and facilitators to implementation of non-medical independent prescribing in primary care in the UK: a qualitative systematic review

ObjectivesTo support workforce deficits and rising demand for medicines, independent prescribing (IP) by nurses, pharmacists and allied health professionals is a key component of workforce transformation in UK healthcare. This...

Pharmacist led homeless outreach engagement and non-medical independent prescribing (Rx) (PHOENIx) intervention for people experiencing homelessness: a non- randomised feasibility study

BackgroundHomelessness and associated mortality and multimorbidity rates are increasing. Systematic reviews have demonstrated a lack of complex interventions that decrease unscheduled emergency health services utilisation or increase scheduled care. Better evidence is needed to inform policy responses. We examined the feasibility of a complex intervention (PHOENIx: Pharmacist led Homeless Outreach Engagement Nonmedical Independent prescribing (Rx)) to inform a subsequent pilot randomised controlled trial (RCT).MethodsNon-randomised trial with Usual Care (UC) comparator group set in Greater Glasgow and Clyde Health Board, Scotland. Participants were adult inpatients experiencing homelessness in a city centre Glasgow hospital, referred to the PHOENIx team at the point of hospital discharge, from 19th March 2018 until 6th April 2019. The follow up period for each patient started on the day the patient was first seen (Intervention group) or first referred (UC), until 24th August 2019, the censor date for all patients. All patients were offered and agreed to receive serial consultations with the PHOENIx team (NHS Pharmacist prescriber working with Simon Community Scotland (third sector homeless charity worker)). Patients who could not be reached by the PHOENIx team were allocated to the UC group. The PHOENIx intervention included assessment of physical/mental health, addictions, housing, benefits and social activities followed by pharmacist prescribing with referral to other health service specialities as necessary. All participants received primary (including specialist homelessness health service based general practitioner care, mental health and addictions services) and secondary care. Main outcome measures were rates of: recruitment; retention; uptake of the intervention; and completeness of collected data, from recruitment to censor date.ResultsTwenty four patients were offered and agreed to participate; 12 were reached and received the intervention as planned with a median 7.5 consultations (IQR3.0–14.2) per patient. The pharmacist prescribed a median of 2 new (IQR0.3–3.8) and 2 repeat (1.3–7.0) prescriptions per patient; 10(83%) received support for benefits, housing or advocacy. Twelve patients were not subsequently contactable after leaving hospital, despite agreeing to participate, and were assigned to UC. Two patients in the UC group died of drug/alcohol overdose during follow up; no patients in the Intervention group died. All 24 patients were retained in the intervention or UC group until death or censor date and all patient records were accessible at follow up: 11(92%) visited ED in both groups, with 11(92%) hospitalisations in intervention group, 9(75%) UC. Eight (67%) intervention group patients and 3(25%) UC patients attended scheduled out patient appointments.ConclusionsFeasibility testing of the PHOENIx intervention suggests merit in a subsequent pilot RCT.

Achieving and maintaining competency as a nurse independent non-medical prescriber

Prescribing practice within the United Kingdom has evolved, with many non-medical healthcare professionals holding or requiring prescribing rights as part of their role. This article outlines how the competencies of a nurse independent non-medical prescriber are achieved and maintained. It aims to inform prospective nurse independent non-medical prescribers and their organisations what is expected of during Independent Non-Medical Prescriber training and what their responsibilities will be to maintain competencies when qualified. The Competency Framework for all Prescribers is highlighted throughout the article for its essential role in Independent Non-Medical Prescriber training and practice.

Independent non-medical prescribing in a nurse-led hospice: strengths and challenges

Independent non-medical prescribing has been a safe, effective and economical initiative for St Teresa's nurse-led hospice, as indicated by yearly audits of prescribing charts and incident reports. However, there are several challenges involved, some shared with other palliative care organisations and some unique to this hospice. These include accessing consistent evidence, especially in light of high volumes of off-licence or unlicensed prescribing with limited stock of medication, and pro-actively pursuing tailored Continuous Professional Development. These challenges, though sometimes complex, are not insurmountable for the experienced non-medical prescribers in this non-conventional setting.

Non-medical prescribing in the United Kingdom National Health Service: A systematic policy review.

IntroductionNon-medical prescribing was introduced into the United Kingdom (UK) to improve patient care, through extending healthcare professionals’ roles. More recent government health service policy focuses on the increased demand and the need for efficiency. This systematic policy review aimed to describe any changes in government policy position and the role that non-medical prescribing plays in healthcare provision.MethodThe systematic policy review included policy and consultation documents that describe independent non-medical prescribing. A pre-defined protocol was registered with PROSPERO (CRD42015019786). Professional body websites, other relevant websites and the following databases were searched to identify relevant documents: HMIC, Lexis Nexis, UK Government Web Archive, UKOP, UK Parliamentary Papers and Web of Science. Documents published between 2006 and February 2018 were included.Results and discussionFollowing exclusions, 45 documents were selected for review; 23 relating to policy or strategy and 22 to consultations. Of the former, 13/23 were published 2006–2010 and the remainder since 2013. Two main themes were identified: chronological aspects and healthcare provision. In the former, a publication gap for policy documents resulted from a change in government and associated major healthcare service reorganisation. In the later, the role of non-medical prescribing was found to have evolved to support efficient service delivery, and cost reduction. For many professions, prescribing appears embedded into practice; however, the pharmacy profession continues to produce policy documents, suggesting that prescribing is not yet perceived as normal practice.ConclusionPrescribing appears to be more easily adopted into practice where it can form part of the overall care of the patient. Where new roles are required to be established, then prescribing takes longer to be universally adopted. While this review concerns policy and practice in the UK, the aspect of role adoption has wider potential implications.

Barriers to and facilitators of the implementation and utilisation of independent non-medical prescribing: a mixed methods systematic review

Purpose: To establish an evidence base identifying previously reported existing barriers to, or facilitators of, the implementation and/or utilisation of non-medical prescribing (NMP).

Facilitators and barriers to non-medical prescribing - A systematic review and thematic synthesis.

IntroductionNon-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom.MethodsThe systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786).ResultsOf 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals’, ‘area of competence’, ‘impact on time’ and ‘service’. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances.DiscussionAddressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists.

Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review

What are the factors that affect the implementation or utilisation of independent non-medical prescribing (iNMP)? Mixed-methods systematic review. Two reviewers independently completed searches, eligibility and quality assessments. Pre-defined search terms were utilised to search electronic databases. Reference lists, key journals and grey literature were searched alongside consultation with authors/experts. Qualitative and quantitative studies investigating independent prescribing by any non-medical professional group. Study participants included any stakeholders involved in actual or proposed iNMP. Measurements reported on data describing stakeholders' perceptions and experiences of the barriers to/facilitators of iNMP. A total of 43 qualitative and seven quantitative studies from three countries (n=12, 117 participants) were included. Quality scores varied from 9 to 35 (Quality Assessment Tool for Studies with Diverse Designs, 0 to 48). Qualitative data were synthesised into four themes (and subthemes): systems (government and political, organisational, formulary); education and support (non-medical prescribing (NMP) courses/continuous professional development (CPD)); personal and professional (medical profession, NMP professions, service users); and financial factors. Quantitative data corroborated the qualitative themes. Integration of the qualitative themes and quantitative data enabled the development of a NMP implementation framework. Barriers to and facilitators of the implementation and utilisation of iNMP are evident, demonstrating multifactorial and context-specific variables within four explicit themes. Professional bodies, politicians, policy and healthcare managers and clinicians could use the resulting NMP implementation framework to ensure the safe and successful implementation and utilisation of NMP. Clinical physiotherapists and other clinicians should consider whether these variables have been adequately addressed prior to adopting NMP into their clinical practice. PROSPERO CRD42015017212. [Noblet T, Marriott J, Graham-Clarke E, Rushton A (2017) Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review. Journal of Physiotherapy 63: 221-234].

Independent non-medical prescribing in children's hospices in the UK: a practice snapshot.

Non-medical prescribing is well established within the British health service, with increasing numbers of nurses practicing within children's hospices. To identify the context of non-medical prescribing in children's hospices in the UK, focusing on the perceived benefits and challenges. Internet-based questionnaires were sent to 55 UK children's hospices, exploring the practice and context of prescribing. Of the 55 invited, 20 children's hospices responded to the questionnaire, 14 of which employed a total of 39 non-medical prescribers (NMPs). Sixteen individual NMPs responded, of which half (50%) prescribed to enable the continuation of existing medicines, 37.5% prescribed independently surrounding symptom management and control and 31.3% in end-of-life care. Perceived benefits of prescribing included timely access to medicines, increased efficiency and accuracy in the admissions process and medicine reconciliation and the increased ability to offer choice in the place of palliative and hospice care. Perceived barriers to prescribing surrounded opportunities to develop confidence, defining the scope of practice and the time required to assess, diagnose and treat. NMPs are making a significant contribution to the prescribing workforce within hospices; however, a number of challenges need to be addressed to enable hospices to realise the benefits.

Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom.

Prescribing is a complex and error-prone task that demands expertise. McLellan etal.'s theory of expertise development model ("the model"), developed to assess medical literature on prescribing by medical students, proposes that in order to develop, individuals should deliberately engage their knowledge, skills and attitudes within a social context. Its applicability to independent prescribers (IP) is unknown. A systematic review was conducted to explore whether the model is applicable to non-medical independent prescribing and to assess the factors underpinning expertise development reported in the literature. Six electronic databases (EMBASE, Medline, AMED, CINAHL, IPA and PsychInfo) were searched for articles published between 2006 and 2016, reporting empirical data on pharmacist and nurse IPs education or practice. Data were extracted using themes from the model and analysed using framework analysis. Thirty-four studies met the inclusion criteria. Knowledge, pre-registration education, experience, support and confidence were some of the intrinsic and extrinsic factors influencing IPs. Difficulty in transferring theory to practice was attributed to lack of basic pharmacology and bioscience content in pre-registration nursing rather than the prescribing programme. Students saw interventions using virtual learning or learning in practice as more useful with long-term benefits e.g. students were able to use their skills in history taking following the virtual learning intervention 6-months after the programme. All studies demonstrated how engaging knowledge and skills affected individuals' attitude by, for example, increasing professional dignity. IPs were able to develop their expertise when integrating their competencies in a workplace context with support from colleagues and adherence to guidelines. This is the first study to synthesize data systematically on expertise development from studies on IPs using the model. The model showed the need for stronger foundations in scientific knowledge amongst some IPs, where continuous workplace practice can improve skills and strengthen attitudes. This could facilitate a smoother transfer of learnt theory to practice, in order for IPs to be experts within their fields and not merely adequately competent.

Nurse prescribing in mental health: Does it still make sense?

Several authors have previously identified the benefits of nurse prescribing in mental health care highlighting the establishment of a therapeutic relationship, empowering patients to make choices and modern ways of working. However, unlike other disciplines in nursing such as diabetes, tissue viability and respiratory care, registered mental health nurses (RMN) who have completed the non-medical independent prescribing qualification appear reluctant to prescribe. Some areas of mental health care provision such as memory clinics and substance misuse services have recognised nurse prescribing as a specialist role; however, within inpatient and community care settings the uptake of nurse prescribers actually prescribing remains low; therefore, this article will attempt to identify the possible reasons why.

Independent non-medical prescribing for paramedics.

Independent non-medical prescribing has made significant advances in nursing and is now being considered and developed by other professions. The role of the paramedic is evolving and there is great emphasis on managing people at home and reducing rates of conveyance to hospital. This article discusses the role of the paramedic and suggests the benefits that independent non-medical prescribing could have for both the paramedic profession and for the patients paramedics treat during their clinical practice.