Exploring facilitators and barriers to scope of practice expansion with Pharmacist independent prescribers in North Wales: a qualitative study
Authors: Davies R L Kloss , Deslandes R , Yemm R 
Published: November 2024

Abstract

Introduction
Independent non-medical prescribing allows qualified nurses, pharmacists and other healthcare professionals to prescribe within their competence, which is initially narrow in scope. Previous research identified that this competence requirement has potential to limit pharmacist independent prescribers’ (PIPs) ability to expand their prescribing scope1. The Royal Pharmaceutical Society has published guidance for PIPs on expanding scope of practice after qualification2. Research asking how, why and what factors affect the process of scope expansion is lacking.

Aim
To explore the reasons why PIPs may or may not expand their prescribing scope of practice after qualification and what factors may prevent or enable this.

Methods
A qualitative semi-structured interview study was utilised. Participants were PIPs working within North Wales who self-reported at least 2 years’ experience as a prescriber, prescribing at least monthly and had expanded their scope of practice since qualification. Recruitment was via gatekeepers. The study obtained ethical approval from Cardiff University School of Pharmacy Research Ethics Committee (Reference 2324-03) and was registered with Betsi Cadwaladr University Health Board. Purposive sampling ensured inclusion of pharmacists from multiple pharmacy sectors. Interviews were face-to-face or online and recorded on MSTeams®. Deidentified verbatim transcripts were analysed via inductive thematic analysis.

Results
Ten participants were interviewed, from a mixture of hospital, primary care, out of hours and community pharmacy sectors. Themes identified included intrinsic factors (experience and attitude) and extrinsic factors (support, service factors, governance and workplace social context). Experience sub-themes included confidence, a holistic approach and awareness of professional boundaries as facilitators for scope expansion. Attitude included being motivated and fulfilment in the role. Support was a key factor including time, funding, mentorship, peer and managerial support – all identified as facilitators and lack of each as a barrier. Other support sub-themes included structured training programmes, such as the All Wales 111 competency framework, easy access to experienced colleagues for advice on cases and space for reflective thinking, either as a team or with a mentor. Governance was identified as both a barrier and facilitator, with some appreciating the structure of local prescribing policies whilst others found it restrictive. Service factors included new roles, an expectation of the role to prescribe for multiple conditions, such as in 111 or the community pharmacy independent prescribing service, changes in team skill mix, service review and patient requests. Workplace social context that facilitated scope expansion included independent prescriber role models, nurturing teams and working within a multidisciplinary team. A lack of multidisciplinary working, such as lone working in community pharmacy, was seen as a barrier.

Discussion / Conclusion
Themes identified align with previously published literature and models on expertise development in independent prescribing(4), suggesting that expanding scope of prescribing aligns with expert practice development needs. This exploratory study highlights factors that PIPs found both helpful and a hindrance for expanding their prescribing scope of practice, although limited by the small sample size. Further research is needed to corroborate these findings with other professions and in other parts of the UK before incorporating into future guidance.

References
1. Main H, McIntosh T, Cunningham S. A qualitative, theoretically based study exploring the influences which shape secondary care pharmacists' self imposed prescribing boundaries. Int J Pharm Pract. 2020;28(Supplement 2):5-6.
2. Royal Pharmaceutical Society. Professional Guidance: Expanding Prescribing Scope of Practice. 2022 [accessed 29/05/2023]. Available from: https://www.rpharms.com/resources/frameworks/prescribing-competency-framework/supporting-tools/expanding-prescribing-scope-of-practice
3. Abuzour AS, Lewis PJ, Tully MP. Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom. Res Social Admin Pharm. 2018;14(1):6-17.