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

  • Emma Graham-Clarke ,

    Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft

    EMG315@bham.ac.uk

    Affiliation School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom

  • Alison Rushton,

    Roles Conceptualization, Methodology, Supervision, Validation, Writing – review & editing

    Affiliation Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom

  • Timothy Noblet,

    Roles Conceptualization, Formal analysis, Investigation, Methodology, Writing – review & editing

    Affiliation Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom

  • John Marriott

    Roles Conceptualization, Methodology, Supervision, Writing – review & editing

    Affiliation School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom

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

  • Emma Graham-Clarke, 
  • Alison Rushton, 
  • Timothy Noblet, 
  • John Marriott
PLOS
x

Abstract

Introduction

Non-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.

Methods

The 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).

Results

Of 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.

Discussion

Addressing 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.

Introduction

The drive behind non-medical prescribing in the United Kingdom (UK) is the need to deliver high-quality healthcare to patients where and when they require it, within a limited financial resource [13]. Innovative patient centred care pathways are being developed, using the most appropriate healthcare professionals, such as clinical pharmacists in general practice [4], or prescribing physiotherapists streamlining musculoskeletal pathways [5]. The extension of non-medical prescribing to other professional groups continues; with pressure for physician associates to become prescribers [6] and paramedics; who were unsuccessful at the last consultation [7].

Non-medical prescribing evolved from limited list prescribing for a few nurses in the early 1990s to the current range of eligible healthcare professionals (Table 1). Each healthcare professional must successfully complete an appropriate and approved prescribing course, and be registered as a prescriber with their relevant regulatory body. Professionally, they are expected to prescribe within their competency area [8, 9].

The initial uptake of non-medical prescribing was slow, with approximately 240 pharmacists and 4000 nurses having qualified by 2005 [10], the later contrasting with the government’s anticipated 10000 nurses [11]. A recent report identified that approximately 53000 nurses and over 3800 pharmacists were registered as prescribers in 2015 [12], but was unable to identify how many were active. Previous survey evidence indicated 14% of nurse independent prescribers and 29% of pharmacist independent prescribers were not using their prescribing qualification [10], and other estimates [13] indicate under 10% of nurse independent prescribers and nearly 40% of pharmacist and allied health professional prescribers are not using their prescribing qualification. Similarly, surveys conducted by the General Pharmaceutical Council indicate varying uptake of prescribing activity. In a 2016 survey of prescribing pharmacists nearly 90% of pharmacist prescribers were reported as active [14], whereas the previous 2014 report had found that only 61% had prescribed in the previous year [15]. The 2016 survey had a poor response rate (<18%) possibly overestimating activity through responder bias.

The full cost of training a non-medical prescriber (NMP) has been calculated as approximately £10000 [10] and, with increasing demand on the NHS and limited funding, there is a need to realise the full benefit of training investment. Previous studies have identified reasons for not prescribing including lack of support from colleagues or within their work environment [13, 14], or a role change [10]; but did not explore these issues in depth. A previous thematic literature review of supplementary prescribing did not address the issue of barriers and facilitators specifically, but identified a limited number including: medical practitioner support, communication, resource limitations and specific supplementary prescribing aspects [16]. It also did not address independent prescribing. There has been no robust review of the qualitative literature relating to barriers or facilitators of independent non-medical prescribing. Identifying facilitators and barriers to independent non-medical prescribing has the potential for strategy development to optimise its implementation.

The aim of this review was to evaluate the use, facilitators, and barriers of independent non-medical prescribing in primary and secondary care in the UK.

Methods

Search strategy and selection criteria

A systematic review and thematic synthesis was conducted to explore the barriers and facilitators to non-medical independent prescribing in the UK. A protocol for the review was developed in advance, following the PRISMA-P statement [17], and registered with PROSPERO (CRD42015019786). The results are reported in accordance with the PRISMA and ENTREQ statements (S1 and S2 Appendices) [18, 19].

Qualitative and mixed methods research studies investigating independent non-medical prescribing in the UK were included. Narrative reports describing a service, opinion papers and abstracts were excluded [20]. The legislation permitting independent prescribing by nurses and pharmacists was enacted in 2006 and therefore only studies published since 2006 were included [21]. There was no language restriction.

Specific search strategies were developed with expert librarian support, for each electronic database, and included broad and narrow, free text, and thesaurus based terms [22]. Boolean operators and truncation were used. The selected keywords were: nurse, pharmacist, physiotherapist, podiatrist, non-medical, therapist, allied health professional, chiropodist, independent prescribing, utilisation, barriers, facilitators, role, education, support, guidelines, policy, procedures, attitudes and clinic. The following databases were searched: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of science. Papers that cite, or were cited by, the included papers were screened to identify any further relevant papers. Searches were completed to 26 March 2017 (S3 Appendix. Medline (Ovid) search strategy).

Titles/abstracts obtained from all searches were screened to remove duplicates and papers that did not meet the eligibility criteria. Full text copies of the papers remaining were obtained and reviewed. Two independent reviewers (EGC and TN) conducted each stage and resolved differences by discussion, with a third reviewer (AR) available for mediation if required [23]. Numbers excluded at each stage were recorded [18, 23].

Quality assessment

A validated quality assessment tool, (Quality Assessment Tool for Studies of Diverse Designs, QATSDD), was used to assess the studies [24]. The tool was developed to support quality analysis where studies use different designs, including qualitative, quantitative, and mixed methods. The tool comprises 16 elements (listed in S1 Table. QATSDD scores for each paper) covering aspects such as theoretical approach, research setting, data collection, and method of analysis. Each element is rated on a scale of 0 –no evidence, to 3 –full details, with clear reasons defined for each score. Twelve elements are common to all studies, with two specific elements each for qualitative and quantitative studies. The studies included in this review used a variety of research methods, primarily interviews, questionnaires and focus groups, making this tool suitable. Two reviewers (EGC and TN) independently assessed the studies using the tool; resolving any disagreement in the scores through discussion. Including low quality studies in a qualitative systematic review is debated, with some researchers arguing for their inclusion as they may provide valuable insights, whereas others argue they should be excluded [20, 25, 26]. The decision was taken to include all studies to inform synthesis and conclusions regardless of quality assessment, but to report on the quality assessment results (see Table 2), particularly as from an initial scoping search, limited studies were identified.

Analysis

Thematic analysis, to identify recurrent barriers and facilitators to non-medical prescribing and themes relating to use, was conducted on text from the results and findings sections of the papers together with any included participant quotations [69, 70]. The studies were read to identify initial emerging themes, and then underwent line by line thematic coding utilising NVivo®11 (QSR International). As further themes emerged, new codes were created. All codes and themes were reviewed iteratively for consistency and appropriateness and amended if necessary. The findings were summarised under descriptive theme headings, permitting development of a hierarchy. The analysis was conducted by one researcher (EGC) and the initial themes and coding discussed and critically debated by all authors. The final version was agreed by all authors following further refinement of the theme headings and hierarchy. At the end of data analysis no further themes were identified, indicating that data saturation had been reached [70]. EGC is a practising NMP, and an NMP lead with a role in supporting other NMPs. This researcher standpoint was balanced by the other three authors, none of whom are prescribers.

Results

The search strategy identified 3991 potentially relevant studies. Following exclusion of 459 duplicates and 3436 from title and abstract review, 96 studies were reviewed at the full text stage. Following exclusions, 42 papers were included (Fig 1. PRISMA flow diagram).

Overall, the studies were assessed as moderate quality. There were three low scoring papers [30, 57, 58] (score <25%), and four high scoring papers [27, 31, 43, 52] (score >75%); the latter being doctoral theses (S1 Table. QATSDD scores for each paper). Key issues highlighted by the scores were poor reporting of theoretical framework, data collection tool choice, analytical method justification, research question and analytical method fit, and user involvement.

Of the 42 papers, 30 (71%) were published between 2007 and 2012, with the remainder published subsequently. Nurse independent prescribers were studied in 24 papers [2832, 3438, 40, 42, 44, 46, 48, 50, 5860, 62, 6467], pharmacist prescribers in five papers [43, 49, 54, 55, 57], and a mixture of nurse and pharmacist prescribers in a further six papers [27, 33, 47, 52, 53, 61]. The remaining papers investigated the views of patients and staff associated with NMPs [39, 41, 45, 51, 56, 63, 68].

Thematic analysis identified 17 subthemes of which 15 described the factors that may impact on NMPs and two described the range of activity. These were grouped into three overarching themes, which were 1) factors relating to the NMP themselves, 2) human factors and 3) organisational aspects. The themes and subthemes are presented in Table 3, together with example factors, and S2 Table lists the papers that the themes were identified in. The 15 subthemes impacting on non-medical prescribing contained factors which could be barriers or facilitators; in many instances, this was dictated by circumstances.

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Table 3. The themes and subthemes that influence non-medical prescribing.

https://doi.org/10.1371/journal.pone.0196471.t003

Non-medical prescriber themes

Factors affecting the NMP were subdivided into those arising from the attitude of the NMP and those derived from their practice (See Table 3). Prescribing enabled the professional to practice autonomously [21, 28, 31, 37, 42, 46, 65], enhancing job satisfaction [31, 37, 42, 46, 47, 49, 65], and supporting professional development [27, 33, 47, 50]. Some practitioners, however, expressed anxiety [29, 37] and cautiousness [27, 48, 52, 65]. Practitioners indicated that their area of competency enabled them to prescribe confidently [44, 48, 52, 6567], and to resist pressure to prescribe outside this area [34, 44, 52, 6567]. Roles were enhanced through including prescribing [27, 33, 35, 37, 42, 44, 58, 63, 67].

Human factor themes

Human factors described the impact that NMPs had on their patients, colleagues, and managers, and the impact that these people had on the NMP themselves. Medical staff that had been involved in the training of NMPs [39, 54, 63] were more supportive than those who were unaware of the training involved [39, 43]. This was regardless of seniority [55, 66]; junior medical staff were less likely to be supportive [39]. Managers were instrumental in developing and supporting the NMP role [27, 36, 41, 43]. Lack of support, flexibility or understanding by managers hindered the implementation and development of non-medical prescribing [27, 29, 31, 32, 37, 46, 52, 54, 61, 66, 67]. NMPs gained support from colleagues, describing enhanced team working [27, 32, 34, 35, 41, 43, 4749, 55, 57, 6567], and were perceived as supportive experts and leaders [27, 32, 43, 47, 67]. However, NMPs encountered opposition from some colleagues [21, 27, 31, 32, 38, 43, 44, 47, 52, 62, 66].

Organisational aspect themes

Organisational aspects encompassed a range of themes covering administration, development and service delivery. Administration comprised three subthemes: formulary, policy, and remuneration. A formulary could be self-imposed [27, 31, 32, 48, 52], or organisation derived [27, 29, 31, 32, 36, 62], and while they could be empowering [31, 36, 52, 66], they could be restrictive [27, 29, 32, 36, 48, 52, 62]. Local policies could be supportive [27, 47, 66], restrictive [27, 31, 43, 66], or missing [62]. Remuneration was considered to be non-commensurate with skills [27, 43, 46, 50, 54, 60, 62]. Development covered both training, including selection for course, as well as post course support. Course facilitators included appropriate selection of candidates [35, 39, 41, 45, 47, 50], awareness of course commitments and requirements [48], and support from medical mentors [43, 63], and managers [39, 41, 45]. Post course support included the provision or facilitation of professional development courses [27, 36, 41, 47, 48, 67], mentoring [27, 41, 48, 50], and clinical supervision [27, 36, 66]. Absence of such support hindered NMP development [27, 33, 3537, 43, 46, 48, 52, 62, 63, 66, 67]. Infrastructure covered several issues, each with the potential to support or hinder, including access to: patient records [27, 37, 43, 46, 49, 51, 52, 54, 63, 64], information technology [27, 31, 36, 38, 43, 48], prescriptions [27, 31, 32, 37, 38, 43, 62, 67], and facilities [43, 49]. NMPs spent more time with patients [35, 37, 39, 47, 49, 52, 55, 56, 63, 68], and were considered to provide a responsive, efficient, and convenient service [27, 29, 33, 3537, 40, 44, 4749, 59, 65, 68]. Doctors’ time was released by NMPs activity [29, 36, 43, 51, 63, 67], but time constraints and workload could hinder the NMP service [29, 34, 35, 44, 46, 49, 52, 63]. Some services were now reliant on NMPs [36, 37] and had issues when cover was absent [36]. The settings and patient groups where non-medical prescribing is utilised were diverse. Examples were given of utilising non-medical prescribing to treat patients who may find accessing healthcare difficult such as frail and housebound patients [37, 52, 63], the homeless [52], and drug users [43, 58]. Non-medical prescribing was also utilised in more conventional healthcare settings such as specialist clinics (for example, dermatology [36, 43], anti-coagulation [56], and cardiovascular [43]), minor illness clinics [31, 36, 37, 44, 50], and out-of-hours services [36, 37, 52].

During analysis, it became apparent that many factors were not present in isolation but were interdependent. Frequently, the interdependence was between a member of staff, the NMP, an organisational aspect such as policy, and how this impacted on the NMP’s confidence and ability to prescribe. Examples include a situation whereby a supportive GP had given an NMP confidence to develop her competence area and expand her personal prescribing formulary [27], and identification by NMP leads that an NMP role was more likely to flourish when linked to a strategic vision and a well-defined area of practice [41]. Other interdependencies were within organisational aspects, such as the increased time required when the NMP was unable to easily access the patient’s notes [37], or when the non-medical prescribing policy specifically supported access to continuing training [28].

Discussion

This is the first systematic review to investigate and synthesise the qualitative and mixed methods literature regarding barriers and facilitators to, and use of, independent non-medical prescribing. Three overarching themes, each containing subthemes, were identified; the NMP, human factors and organisational aspects. The themes and subthemes could all impact on successful implementation of non-medical prescribing, and could be interdependent.

The NMP theme describes three aspects; one is intrinsic to the person (attitude), one derives from their role, and the final one may be personally or externally derived. The later subtheme ‘Area of competence’ was one of the four most highly mentioned aspects found during analysis, highlighting its importance. This is supported by the ‘Competency framework for all prescribers’ [8] and the NMC ‘Standards of proficiency for nurse and midwife prescribers’ [9], which state that practitioners should only prescribe within their scope of practice (in contrast with the traditional medical model). There are implications if the NMP changes role, or in planned service expansion, as further training and support in these new areas would be required. Closely defined areas of competence could hamper full utilisation of non-medical prescribing, particularly in patients with co-morbidities.

The second theme ‘human factors’ describes the complex interrelation between the NMP, their managers, peers, the medical professions they work with, and their patients. This theme included the most frequently mentioned subtheme ‘Medical professionals’, identified in 32 papers. It is notable that, in contrast with the review by Cooper et al, medical professionals generally accepted the NMP role [16]. Reasons for acceptance may be because non-medical prescribing has become established practice but also because NMPs have made deliberate efforts to gain trust. There was an appreciation that the NMP role permitted medical professionals to concentrate on patients where their expertise was necessary. Changes in managerial personnel could adversely impact on non-medical prescribing, particularly where systems and processes were not embedded into practice. This review found that patients’ views of non-medical prescribing were mixed, with many patients appreciating the time taken and holistic approach of the NMP, whereas others expressed concerns. A lack of public understanding of non-medical prescribing remains, even with patients treated by NMPs. Cooper et al noted that very little research was identified investigating the views of patients about non-medical prescribing [16]. This review identified one paper investigating public perception of non-medical prescribing [51] and eight papers that included the views of patients [27, 28, 40, 49, 56, 59, 61, 68]; however, one of these only included quantitative ‘rating’ data from patients [40]. Research into patients’ opinions of non-medical prescribing warrants further investigation.

The final theme covers the organisational aspects that support and enable an NMP to practice. It contains two of the four most frequently mentioned subthemes, ‘impact on time’ and ‘service’. In comparison to other subthemes, these two were frequently interdependent on each other, with both highlighting the perceived improvement to patient care by providing a streamlined, holistic, and convenient service. Funding pressures may make this aspect of the service, appreciated by patients, difficult to sustain. This review identified that contingency and succession planning should be considered during service development.

This review’s strength lies in its rigorous methodology and breadth of search strategy. This compares with the previous investigations, which were limited in scope and rigour [14, 16]. The predetermined stringent protocol, registered with PROSPERO, and the use of two independent reviewers are recognised strategies to reduce potential bias associated with paper selection [20, 71]. Limitations included the inconsistent definitions used to describe NMPs, which became apparent during the literature search. The terminology would have been appropriate when those studies were conducted, but the meaning changed as prescribing rights evolved (see Table 1). Every effort was made to limit the included studies to those investigating full independent non-medical prescribing. The nursing profession dominated the included studies, with limited representation from pharmacist prescribers (mentioned in 11 papers [27, 33, 43, 47, 49, 5255, 57, 61]) and none from other non-medical prescribing professions. This reflects the relative numbers of the different professions [15, 72] and the numbers of qualified prescribers [12]. However, the numbers of AHPS are likely to have increased recently following legislation changes and that could be considered a limitation. Research into non-medical prescribing by the other professions is needed to identify if they experience the same barriers and facilitators.

The themes and subthemes identified in this review influence the implementation and development of non-medical prescribing; each could act as a barrier or facilitator depending on circumstances. Where there was a lack of understanding of the non-medical prescribing role, or lack of trust in the non-medical prescriber, then the factors were more inclined to be barriers. For example, medical professionals were less likely to support non-medical prescribing where there was a lack of clarity about who took responsibility for the prescribing practice [35, 39, 50]. Facilitation of NMP occurred when medical professionals trusted the NMP, for example enabling access to patient records [37]. As a consequence of budgetary constraints, factors may become barriers, such as the use of restrictive formularies as a cost saving measure [37, 52, 64]. Additionally, this review has identified that these themes and subthemes do not stand in isolation but are interdependent on each other. Each of these aspects should be considered when developing a non-medical prescribing service, and could be utilised as a model for developing a non-medical prescribing strategy framework. This review will also inform those currently managing or running a service, enabling service optimisation. Failure to address all these aspects may mean that the full benefit of an NMP service will not be realised.

References

  1. 1. NHS England. Five Year Forward View2014 October 2014. Available from: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
  2. 2. NHS England. NHS England sets out proposals for more efficient and responsive access to medicines for patients 2015 [updated 26/02/15; cited 2015 12/13]. Available from: https://www.england.nhs.uk/2015/02/26/access-to-medicines/.
  3. 3. Next steps on the NHS five-year forward view. NHS England; 2017. Available from: https://www.england.nhs.uk/2017/03/next-steps-on-the-five-year-forward-view/.
  4. 4. General Practice Forward View. NHS England; 2016. Available from: https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf.
  5. 5. Loughran I, Rae G. Physiotherapist prescribing in lower back pain: a case study. Nurse Prescribing. 2015;13(2):94–7.
  6. 6. The Health Foundation. Staffing matters; funding counts. London: The Health Foundation; 2016. Available from: http://www.health.org.uk/sites/health/files/StaffingMattersFundingCounts.pdf.
  7. 7. Allied Health Professions Medicines Project Team. Summary of the responses to the public consultation on proposals to introduce independent prescribing by paramedics across the United Kingdom. NHS England,; 2016. Available from: https://www.england.nhs.uk/wp-content/uploads/2016/02/Paramedics-summary-consult-responses.pdf.
  8. 8. A competency framework for all prescribers. London: Royal Pharmaceutical Society; 2016. Available from: https://www.rpharms.com/resources/frameworks/prescribers-competency-framework.
  9. 9. Standards of proficiency for nurse and midwife prescribers. Updated 2015 ed. London: Nursing and Midwifery Council; 2006. Available from: https://www.nmc.org.uk/standards/additional-standards/standards-of-proficiency-for-nurse-and-midwife-prescribers/.
  10. 10. Latter S, Blenkinsopp A, Smith A, Chapman S, Tinelli M, Gerard K, et al. Evaluation of nurse and pharmacist independent prescribing: University of Southampton; Keele University; 2010 October 2010. 374 p.
  11. 11. Department of Health. Patients to get quicker access to medicines Richmond House, 79 Whitehall, London SW1A 2NJ, UK: Department of Health; 2001 [11/08/2014]. Press Release]. Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4010748.
  12. 12. i5 Health. Non-Medical Prescribing (NMP); An Economic Evaluation. NHS Health Education North West, 2015. Available from: https://www.hee.nhs.uk/sites/default/files/documents/Agenda%20Item%207%20-%20i5%20Health%20-%20NMP%20Economic%20Evaluation.pdf.
  13. 13. Courtenay M, Carey N, Stenner K. An overview of non medical prescribing across one strategic health authority: a questionnaire survey. BMC Health Serv Res. 2012;12:138. pmid:22657272
  14. 14. Prescribers Survey Report. London: General Pharmaceutical Council; 2016. p. 54. Available from: https://www.pharmacyregulation.org/sites/default/files/gphc_prescribers_survey_report.pdf.
  15. 15. Phelps A, Agur M, Nass L, Blake M. GPhC Registrant Survey 2013 Findings. London: NatCen, 2014 March 2014. Report No. Available from: https://www.pharmacyregulation.org/sites/default/files/gphc_registrant_survey_2013_main_report_by_natcen.pdf.
  16. 16. Cooper RJ, Anderson C, Avery T, Bissell P, Guillaume L, Hutchinson A, et al. Nurse and pharmacist supplementary prescribing in the UK-a thematic review of the literature. Health Policy. 2008;85(3):277–92. pmid:17900744
  17. 17. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews. 2015;4(1):1–9. pmid:25554246
  18. 18. Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLOS Med. 2009;6(7):e1000097. pmid:19621072
  19. 19. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12(1):181. pmid:23185978
  20. 20. Hannes K. Chapter 4: Critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, et al., editors. Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions. Version 1 ed2011.
  21. 21. The National Health Service (Miscellaneous Amendments Relating to Independent Prescribing) Regulations 2006, Stat. 913 (1st May 2006).
  22. 22. Shaw RL, Booth A, Sutton AJ, Miller T, Smith JA, Young B, et al. Finding qualitative research: an evaluation of search strategies. BMC Med Res Methodol. 2004;4(5). pmid:15070427
  23. 23. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLOS Med. 2009;6(7):e1000100. pmid:19621070
  24. 24. Sirriyeh R, Lawton R, Gardner P, Armitage G. Reviewing studies with diverse designs: the development and evaluation of a new tool. J Eval Clin Pract. 2012;18(4):746–52. pmid:21410846
  25. 25. Hannes K, Lockwood C, Pearson A. A comparative analysis of three online appraisal instruments' ability to assess validity in qualitative research. Qual Health Res. 2010;20(12):1736–43. pmid:20671302
  26. 26. Sandelowski M, Voils CI, Barroso J. Defining and designing mixed research synthesis studies. Res Sch. 2006;13(1):29. Epub 2006/04/01. pmid:20098638
  27. 27. Adigwe OP. Non-medical prescribing in chronic non-malignant pain [PhD]. Leeds: University of Leeds; 2012.
  28. 28. Armstrong A. Staff and patient views on nurse prescribing in the urgent-care setting. Nurse Prescribing. 2015;13(12):614–9.
  29. 29. Bennett J, Jones M. Nurse prescribing in HIV: opportunities and threats. HIV Nursing. 2008;8(4):12–6.
  30. 30. Bewley T. Preparation for non medical prescribing: a review. Paediatr Nurs. 2007;19(5):23–6. pmid:17621779
  31. 31. Bowskill D. The integration of nurse prescribing: case studies in primary and secondary care [DHSci]. Nottingham: University of Nottingham; 2009.
  32. 32. Bowskill D, Timmons S, James V. How do nurse prescribers integrate prescribing in practice: case studies in primary and secondary care. J Clin Nurs. 2013;22(13–14):2077–86. pmid:23186080
  33. 33. Brodie L, Donaldson J, Watt S. Non-medical prescribers and benzodiazepines: a qualitative study. Nurse Prescribing. 2014;12(7):353–9.
  34. 34. Carey N, Stenner K, Courtenay M. Adopting the prescribing role in practice: exploring nurses' views in a specialist children's hospital. Paediatr Nurs. 2009;21(9):25–9. pmid:19947105
  35. 35. Carey N, Stenner K, Courtenay M. Views on implementing nurse prescribing in a specialist children's hospital. Nurse Prescribing. 2009;7(5):205–10.
  36. 36. Carey N, Stenner K, Courtenay M. Stakeholder views on the impact of nurse prescribing on dermatology services. J Clin Nurs. 2010;19(3–4):498–506. pmid:19747199
  37. 37. Carey N, Stenner K, Courtenay M. An exploration of how nurse prescribing is being used for patients with respiratory conditions across the east of England. BMC Health Serv Res. 2014;14:13.
  38. 38. Courtenay M, Carey N. Nurse independent prescribing and nurse supplementary prescribing practice: national survey. J Adv Nurs. 2008;61(3):291–9. pmid:18197863
  39. 39. Courtenay M, Carey N. Nurse prescribing by children's nurses: views of doctors and clinical leads in one specialist children's hospital. J Clin Nurs. 2009;18(18):2668–75. pmid:19619207
  40. 40. Courtenay M, Carey N, Stenner K. Nurse prescriber-patient consultations: a case study in dermatology. J Adv Nurs. 2009;65(6):1207–17. pmid:19374682
  41. 41. Courtenay M, Carey N, Stenner K. Non medical prescribing leads views on their role and the implementation of non medical prescribing from a multi-organisational perspective. BMC Health Serv Res. 2011;11:142. pmid:21635744
  42. 42. Cousins R, Donnell C. Nurse prescribing in general practice: a qualitative study of job satisfaction and work-related stress. Fam Pract. 2012;29(2):223–7. pmid:21965550
  43. 43. Dapar MP. An investigation of the structures and processes of pharmacist prescribing in Great Britain: a mixed methods approach [PhD]. Aberdeen: Robert Gordon University; 2012.
  44. 44. Daughtry J, Hayter M. A qualitative study of practice nurses' prescribing experiences. Practice Nursing. 2010;21(6):310–4.
  45. 45. Dobel-Ober D, Brimblecombe N, Bradley E. Nurse prescribing in mental health: national survey. J Psychiatr Ment Health Nurs. 2010;17(6):487–93. pmid:20633075
  46. 46. Downer F, Shepherd CK. District nurses prescribing as nurse independent prescribers. Br J Community Nurs. 2010;15(7):348–52. pmid:20733541
  47. 47. Green B, Courtney H. Evaluating the investment: a survey of non-medical prescribing. Mental Health Practice. 2008;12(1):28–32.
  48. 48. Herklots A, Baileff A, Latter S. Community matrons' experience as independent prescribers. Br J Community Nurs. 2015;20(5):217–23. pmid:25993369
  49. 49. Hill DR, Conroy S, Brown RC, Burt GA, Campbell D. Stakeholder views on pharmacist prescribing in addiction services in NHS Lanarkshire. J Subst Use. 2014;19(1–2):56–67.
  50. 50. Kelly A, Neale J, Rollings R. Barriers to extended nurse prescribing among practice nurses. Community Pract. 2010;83(1):21–4. pmid:20196305
  51. 51. Maclure K, George J, Diack L, Bond C, Cunningham S, Stewart D. Views of the Scottish general public on non-medical prescribing. Int J Clin Pharm. 2013;35(5):704–10. pmid:23690252
  52. 52. Maddox C. Influences on non-medical prescribing: nurse and pharmacist prescribers in primary and community care [PhD]. Manchester: University of Manchester; 2011.
  53. 53. Maddox C, Halsall D, Hall J, Tully MP. Factors influencing nurse and pharmacist willingness to take or not take responsibility for non-medical prescribing. Res Social Adm Pharm. 2016;12(1):41–55. pmid:26048711
  54. 54. McCann L, Haughey S, Parsons C, Lloyd F, Crealey G, Gormley GJ, et al. Pharmacist prescribing in Northern Ireland: a quantitative assessment. Int J Clin Pharm. 2011;33(5):824–31. pmid:21830075
  55. 55. McCann L, Lloyd F, Parsons C, Gormley G, Haughey S, Crealey G, et al. "They come with multiple morbidities": A qualitative assessment of pharmacist prescribing. J Interprof Care. 2012;26(2):127–33. pmid:22360391
  56. 56. McCann LM, Haughey SL, Parsons C, Lloyd F, Crealey G, Gormley GJ, et al. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect. 2015;18(1):58–68. pmid:23067131
  57. 57. Mulholland PJ. Pharmacists as non-medical prescribers: what role can they play? The experience in a neonatal intensive care unit. Eur J Hosp Pharm-Sci Pract. 2014;21(6):335–8.
  58. 58. Mundt-Leach R. Non-medical prescribing by specialist addictions nurses. Mental Health Practice. 2012;16(3):28–31.
  59. 59. Oldknow H, Bottomley J, Lawton M. Independent nurse prescribing for older people's mental health. Nurse Prescribing. 2010;8(2):66–9.
  60. 60. Oldknow H, Gillibrand W. Non-prescribing, non-medical prescribers: a qualitative exploratory enquiry—preliminary findings. Mental Health Nursing. 2013;33(4):10–3.
  61. 61. Ross JD. Mental health nurse prescribing: the emerging impact. J Psychiatr Ment Health Nurs. 2015;22(7):529–42. pmid:26031457
  62. 62. Ross JD, Kettles AM. Mental health nurse independent prescribing: what are nurse prescribers' views of the barriers to implementation? J Psychiatr Ment Health Nurs. 2012;19(10):916–32. pmid:22295995
  63. 63. Shannon E, Spence W. The attitudes and views of GPs and physicians to prescribing by heart failure nurse specialists. British Journal of Cardiac Nursing. 2011;6(9):450–5.
  64. 64. Stenner K, Courtenay M. A qualitative study on the impact of legislation on prescribing of controlled drugs by nurses. Nurse Prescribing. 2007;5(6):257–61.
  65. 65. Stenner K, Courtenay M. Benefits of nurse prescribing for patients in pain: nurses' views. J Adv Nurs. 2008;63(1):27–35. pmid:18503536
  66. 66. Stenner K, Courtenay M. The role of inter-professional relationships and support for nurse prescribing in acute and chronic pain. J Adv Nurs. 2008;63(3):276–83. pmid:18702774
  67. 67. Stenner K, Carey N, Courtenay M. Implementing nurse prescribing: a case study in diabetes. J Adv Nurs. 2010;66(3):522–31. pmid:20423387
  68. 68. Stenner KL, Courtenay M, Carey N. Consultations between nurse prescribers and patients with diabetes in primary care: A qualitative study of patient views. Int J Nurs Stud. 2011;48(1):37–46. pmid:20627198
  69. 69. Noyes J, Lewin S. Supplemental Guidance on Selecting a Method of Qualitative Evidence Synthesis, and Integrating Qualitative Evidence with Cochrane Intervention Reviews. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, et al., editors. Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions. Version 1 (updated August 2011) ed: Cochrane Collaboration Qualitative Methods Group; 2011.
  70. 70. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:45. pmid:18616818
  71. 71. EPPI. EPPI-Centre Methods for Conducting Systematic Reviews. London: Evidence for Policy and Practice Information and Co-ordinating Centre, 2010 March 2007. Report No. Available from: http://eppi.ioe.ac.uk/cms/LinkClick.aspx?fileticket=hQBu8y4uVwI=&tabid=1919&mid=6163.
  72. 72. Nursing and Midwifery Council. Annual Report and Accounts 2016–2017 and Strategic Plan 2017–2018. 2017 17 July 2017. Report No.: HC 154. Available from: https://www.nmc.org.uk/globalassets/sitedocuments/annual_reports_and_accounts/annual-report-and-accounts-2016-2017.pdf.