Enablers and barriers to pharmacists and nurses becoming independent prescribers

In the UK, ‘non-medical prescriber’ (NMP) is an umbrella term that describes all health professionals, except physicians and dentists, who have completed a higher qualification in prescribing and are legally authorised to prescribe medications to patients (Cope et al, 2016). To commence their prescribing responsibilities, NMPs must complete an approved prescribing course and register with their relevant professional bodies (Noblet et al, 2017). Non-medical prescribing mainly comprises two models: supplementary non-medical prescribing (sNMP) and independent non-medical prescribing (iNMP).

Nurses and pharmacists were given supplementary prescribing rights in 2003, permitting them to prescribe medications under patient agreement (Department of Health and Social Care (DHSC), 2005). To proceed to successful supplementary prescribing, a voluntary partnership between the physician and the supplementary prescriber was fundamental to develop an agreed clinical management plan; then, the supplementary prescriber could prescribe medications from the agreed list without physician involvement (DHSC, 2005).

In 2006, independent prescribing was introduced in the UK, allowing qualified nurses and pharmacists to prescribe any licensed medicine independently (DHSC, 2006). The DHSC has defined independent prescribing as ‘prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about clinical management required, including prescribing’ (DHSC, 2006).

In December 2020, the General Pharmaceutical Council released new educational and training standards for future pharmacists to become independent prescribers (IPs) from the point of registration, starting from August 2026 (General Pharmaceutical Council, 2020).

Currently, higher education institutions offer accredited iNMP training programmes throughout the UK. The iNMP programme is a part-time course divided into two curricula: taught courses and practical training (General Pharmaceutical Council, 2019). To prescribe medications safely and effectively, NMPs must follow a single competency framework established by the National Prescribing Centre and updated by the Royal Pharmaceutical Society in 2016 (Royal Pharmaceutical Society, 2016). The implementation of non-medical prescribing permits prescribing by numerous health professionals other than medical doctors, effectively developing and using their clinical skills (Courtenay et al, 2011; Hindi et al, 2019). The purpose of non-medical prescribing is essentially to optimise patient care by increasing access to medications and improving health professionals’ abilities, as well as enhancing healthcare resources and patient choice across a range of healthcare departments (Cope et al, 2016; Stewart et al, 2017).

Recently, the Nursing and Midwifery Council (NMC) stated that there were 692 858 registered nurses between 2020 and 2021, with 90 159 of them NMPs (NMC, 2021). In comparison, the General Pharmaceutical Council revealed that there were 56 851 pharmacists and only 8806 were IPs (General Pharmaceutical Council, 2021; Wickware, 2021). These figures suggest that about 13% of the total number of nurses are prescribers and around 15% of pharmacists are IPs, indicating that there may be barriers preventing both pharmacists and nurses from becoming prescribers. It has been observed by Bourne et al (2016) that one third of pharmacists in the UK do not intend to apply to the IP programme, raising questions about what might influence pharmacists’ intention to become IPs (Bourne et al, 2016). The central question of the study was, What influences pharmacists’ and nurses’ intentional behaviours to become IPs? The specific objectives of the study were to:

• Conduct a series of in-depth interviews with a purposive sample of pharmacists and nurses enrolled in an IP programme at the University of Reading
• Explore pharmacists’ and nurses’ influences in becoming IPs
• Identify personal, environmental and social factors that increase pharmacists’ and nurses’ willingness to become IPs
• Point out the barriers for pharmacists and nurses to become IPs
• Assess the association between the years of experience and pharmacists’ and nurses’ intentional behaviours to become IPs
• Examine the association between the working area and pharmacists’ and nurses’ intentional behaviours to become IPs
• Discover the difference between pharmacists’ and nurses’ attitudes to becoming IPs.

Methods

Study design

The consolidated criteria for reporting qualitative studies (COREQ) checklist was used to guide the reporting of this study. This research comprises a cross-sectional qualitative study using semi-structured interviews. One-to-one interviews were chosen to obtain rich data about the participants, their verbal and non-verbal emotions, their perceptions and their actions in terms of becoming IPs (Glenwick and Jason, 2016).

The semi-structured interviews were intended to last for approximately 20–40 minutes, allowing the researcher to obtain in-depth information from participants in their own words. The interview guide comprised 19 open- and closed-ended questions based on two models of health behaviour: social cognitive theory (SCT) and the theory of planned behaviour (TPB) (Table 1). The interviews sought to comprehend and describe the participants’ attitudes, enablers, barriers and experiences regarding becoming IPs, taking an emic perspective. Both theories provide a hypothetical basis for explaining and understanding the essence of participants’ intended behaviours to becoming IPs.

Theoretical framework

Social cognitive theory states that personal behaviour, driven by needs and desires, is regulated by three interacting sets of factors; namely, personal, behavioural and environmental factors (Figure 1) (Conner and Norman, 2015; Schunk and DiBenedetto, 2020). This model was used to highlight the essential role played by the cognitive and social environment on the motivation process, learning outcomes and self-regulation of the research participants (Conner and Norman, 2015; Schunk and DiBenedetto, 2020).

The theory of planned behaviour proposes that individual decisions to follow a particular behaviour (for example, to become an independent prescriber) are influenced by behavioural intention (such as motivating factors), which are determined by personal attitudes, subjective norms and perceived behavioural control (Figure 2) (Conner and Norman, 2015). This framework was used to assess participants’ beliefs about themselves and their abilities to achieve specific goals and understand their perceptions regarding IP (Conner and Norman, 2015).

Participants in the study and data collection

This project was undertaken at the University of Reading in the UK between February and May 2022. Students were eligible to participate if they were pharmacists or nurses who were enrolled in the IP programme at the University of Reading during the academic year 2021–22 and had access to Microsoft Teams. Before the first interview, the interview questions were piloted with two clinical lecturers, who are IPs at the University, to test the clarity and fluency of the interview questions.

All students enrolled in the IP course received an email with an attached information sheet detailing the purpose of the research and explaining what participants’ contribution would involve. Students who agreed to participate were asked to email the researcher. These participants received a consent form and participant demographic information form to complete and email back to the researcher. On receipt of the completed forms, a mutually convenient time was arranged to conduct the interview. For the purpose of capturing participants’ exact words, the interviews were recorded to enhance the qualitative research design by minimising the loss of richness and descriptive data (Taylor and Bogdan, 1984). The participants were given a £25 voucher as compensation for their time participating in the study.

Sample

There were four cohorts of IP courses at the University of Reading during the 2021–22 academic year. The total number of students across all cohorts was 118 pharmacists and 31 nurses. The participants were recruited using representative sampling in respect of their profession (nurse/pharmacist) and sector (primary/secondary care), in order to answer the research objectives. Participants were recruited until data saturation was reached, which, in qualitative research is defined as ‘the point at which no new information, codes or themes are yielded from data’ (Braun and Clarke, 2021).

Ethical considerations

The study was conducted following ethical approval from the Ethics Committee of the School of Chemistry, Food and Pharmacy Research at the University of Reading and was given a favourable ethical approval for conduct; the ethics approval number was 06/2022.

Data analysis

Thematic analysis was chosen as a flexible method to describe and analyse themes and repetitions in the data using a wide range of qualitative frameworks (Braun and Clarke, 2006). The framework of qualitative thematic analysis described by Braun and Clarke (2006) was used to identify and code participants’ opinions, words and phrases into themes to facilitate, evaluate and distinguish patterns in the collected data (Braun and Clarke, 2006).

The first author reviewed the data line by line, and initially coded data related to the theoretical models (social cognitive theory and the theory of planned behaviour) using a deductive approach (Table 2). New and emergent codes were identified in a consequential and systematic manner, and then distinguished and organised into preliminary theoretical themes. A thematic analysis map was developed in order to outline the key themes and their relationships (Figure 3). Lastly, themes and supporting quotes were discussed with the second author; then, upon agreement, the themes were defined and named. Verbatim quotes were used to illustrate the participants’ voices, and each participant was given a pseudonym which matched their gender and ethnicity.

Results

A total of 20 IP students agreed to be interviewed, of whom 15 were pharmacists and five nurses, representing 12% and 16%, respectively, of the total number of students in the IP course during the 2021–22 academic year (Table 3). The average duration of the one-to-one interviews was 23 minutes for both pharmacists and nurses. The range of pharmacists’ interviews was between 14 and 37 minutes, while nurses’ interviews were between 19 and 29 minutes. Based on the SCT and TPB frameworks, five broad themes were deductively generated from the data regarding the elements that influenced pharmacists’ and nurses’ intentional behaviours to become IPs: attitude; facilitators; barriers; social and environmental influence; and optimism about becoming an independent prescriber.

Theme 1: Attitudes to becoming an IP

Pharmacy and nursing students were excited about becoming IPs.

Many of them felt the qualification would enhance their current role, open up job opportunities and facilitate career progression.

‘It enhances my own work, and it makes me think about the care I give to patients.’ [Fatimah, Primary Care Pharmacist]

As of 2026, graduated pharmacists will become IPs from the point of registration, so many pharmacists were concerned and wanted to become IPs to secure their jobs and not fall behind the new graduates. Some pharmacists claimed that they did not have a choice but to become an independent prescriber because it was a requirement of their job contract. Compared with pharmacists, no nurses mentioned having to become IPs as part of their job contract.

‘I don’t want to be … left behind, you know, unable to prescribe what everybody else can.’ [Jessica, Primary Care Pharmacist]

Theme 2: Facilitators to becoming an independent prescriber

Both the pharmacists and nurses felt that support from work, providing them with time to study and offering workshops and shadowing opportunities to practise their skills, made it easier for them to become IPs.

In addition, many organisations funded their employees to become prescribers, facilitating pharmacists and nurses qualifying.

‘I think work definitely made it easier; they have encouraged us to apply for the course and they have given me the time off, they offered to pay for my course as well.’ [Ava, Primary Care Nurse]

Some participants were very satisfied with their designated prescribing practitioners (DPPs) and believed that having a supportive supervisor and colleagues would help them to become better IPs.

‘My supervisor, he was someone that would give me the time and time to teach, and it was in an area that I knew I enjoyed.’ [Aishah, Primary Care Pharmacist]

Theme 3: Barriers to becoming an independent prescriber

Pharmacists and nurses believed that time constraints were the main barrier to becoming IPs because they had to complete the 6-month intensive course while working in a full-time job. A few nurses said that their employers were reluctant to allow them to do the IP course because they believed that nurses were educated differently from pharmacists and doctors.

‘In my workplace, it’s not really giving me any extra time to study and working full time is definitely a barrier.’ [Alexandra, Primary Care Pharmacist]

Almost all the pharmacists and nurses felt that the IP qualification would increase their workload and responsibilities. In addition, they were extremely anxious that medical staff would expect them to be able to prescribe for any conditions. However, few pharmacists stated that healthcare providers used IPs to manage their workloads rather than using them correctly.

‘Unfortunately, the qualification gets seen as a tick-box exercise, like, get IPs to do any work rather than where they would be best placed.’ [Kiara, Primary Care Pharmacist]

Theme 4: Social and environmental influences

Almost all participants said that being surrounded by IPs helped them to understand the role and draw on their experience. They perceived that the IPs had a higher status than themselves. Participants believed that having a prescribers’ network gave them the confidence to become IPs, as they felt that they would not be alone when they started prescribing.

‘I suppose I perceived them as being higher than me. They influence me by making me feel that I would like to be a decision maker and that I could benefit patients as well.’ [Samantha, Primary Care Nurse]

Some of the pharmacists believed that IPs were undervalued, and had seen colleagues not use their qualifications to prescribe. Many participants argued that IPs hid their capabilities because they did not want to be forced to prescribe, or perhaps they did not have a desire to prescribe. A few pharmacists stated that those IPs only used their qualifications to display them on their CVs. However, many of the participants did not even know whether they had IPs on their team, while one of the participants emphasised that they were just like normal healthcare providers with nothing more to offer.

‘I don’t feel like they’re doing anything special, they are just like normal pharmacists. They don’t do anything extra because they’re trying to avoid their responsibility, I guess!’ [Norah, Secondary Care Pharmacist]

Theme 5: Optimism about becoming an independent prescriber

The interviews revealed a strong relationship between the participants’ work history and their preparedness to become IPs. The pharmacists and nurses emphasised that multiple years of experience gave them the confidence to start prescribing. Some participants believed that nobody could underestimate experience because those years helped them to see future job prospects through exposure to different clinical specialties.

‘These years helped me develop my clinical decision-making skills and my clinical judgment; we do daily word rounds, and that gave me enough exposure to different complex patients.’ [Clara, Secondary Care Nurse]

The interviews revealed a strong relationship between the participants' work history and their preparedness to become independent prescribers

It was noted that there was a relationship between participants’ area of work and their willingness to become IPs. Some participants argued that it did not matter how many years of experience pharmacists or nurses had, but rather where they had had this experience. Almost all the pharmacists believed that having experience in a hospital or GP surgery would guarantee better clinical exposure, making it easier to become a prescriber. One of the pharmacists who worked in the Frailty Hub reported that she was lucky because she did not have to deal with prescribing pressure compared to prescribing in a community setting (Table 4).

‘If you work in a hospital you have more access to resources, you’re more likely to get your protected time. But if you work in the community sector, especially for a private organisation, then it gets a bit tricky.’ [Ella, Secondary Care Pharmacist]

Discussion

To our knowledge, this is the first study to use two theoretical models to explore the factors that influence the intended behaviours of pharmacists and nurses enrolled on an IP course and to identify facilitators and barriers to becoming IPs. The TPB model integrated these complex factors that influence the intentional behaviours of becoming IPs. The use of SCT revealed the cognitive and social environmental factors that influence pharmacists’ and nurses’ motivation to undertake IP programmes. Therefore, to understand why participants want to become prescribers and what would increase their willingness to be involved in this role, which enhances the efficacy and productivity of healthcare outcomes, it is important to consider these factors.

Attitude was found to be the most prominent theme in the literature; it determined how NMPs practise their role in primary and secondary care. In the current study, it was found that both pharmacists and nurses demonstrated positive attitudes and a willingness to progress, which enhanced their intention to become IPs.

There were similarities between the attitudes expressed by participating nurses in this study and those described in other recent studies, which revealed that nurses had positive attitudes and beliefs regarding prescribing and its impact on their profession and patient care (Scrafton et al, 2012; Haririan et al, 2021; Haririan et al, 2022).

A comparison study reported that pharmacists in Canada and Australia thought that having the authority to prescribe permitted them to practice their careers at the level of their education (Charrois et al, 2013). These results may indicate the possibility of predicting how successful IP programme students will be in their prescribing roles by considering their positive attitude towards becoming IPs (Haririan et al, 2021).

Under the facilitator theme, a collaborative work environment was found to enhance the participants’ willingness to become IPs. This result was in accordance with a recent qualitative systematic review, which indicated that the quality of supervision and support time during the IP programme strongly influenced student learning experiences (Edwards et al, 2022). It was shown that well-prepared training mentors and effective mentor–student relationships delivered a higher input level to students and enhanced their transition to prescribers (Edwards et al, 2022). In contrast, another study, which used a web-page questionnaire targeting clinical pharmacists working in critical care in the UK, indicated that more than 60% of the participants reported that the absence of colleagues checking prescriptions for IPs was the main clinical barrier for unqualified pharmacists to become prescribers (Bourne et al, 2016). In addition, other research found that a lack of support for the prescribing role negatively influenced nurses’ desires to prescribe (Ross and Kettles, 2012). These findings draw attention to the importance of considering a collaborative approach to practice. This could facilitate pharmacists’ and nurses’ transition to become IPs and confidently practise their prescribing roles in the future.

In terms of barriers, time constraints were reported as the most significant barrier to becoming IPs. This finding was also reported by Mills et al (2021) and Edwards et al (2022) They found that non-medical prescribing students considered that completing the IP programme alongside existing duties was challenging, given how difficult it was to balance their career, study and leisure time (Mills et al, 2021; Edwards et al, 2022).

These findings may help professional regulators understand the difficulties faced by IP programme students that limit their intention to become prescribers. It is, therefore, suggested that there is a need to provide a better balance in students’ lifestyles, primarily between their work environment, academic duties and personal time. Moreover, in this study, having qualified, the natural fear of new responsibilities and liability were reported as the main impediments to using an IP qualification.

A study in 2015 used semi-structured interviews and focus groups to explore the continuing professional development needs of nursing and allied health professionals (AHPs) to meet the clinical demands of the prescribing role (Weglicki et al, 2015). The authors reported that participants expressed anxiety when prescribing due to the fear of making inappropriate decisions or being unable to recall the required theory, resulting in vulnerability and culpability in prescribing (Weglicki et al, 2015). The study also raised the important question of why practitioners want to become prescribers: the role itself, as a requirement of a professional post, or to be seen as a provider of cost-effective services (Weglicki et al, 2015). This combination of findings may indicate that participants with a stronger intention to become IPs are more likely to perform the role as intended (Ajzen, 1991).

Under the social and environmental influence theme it was reported that being surrounded by dynamic IP role models motivated some participants to become involved in prescribing, and enhanced their confidence and understanding of the role. However, other participants argued that some IPs hid their qualifications and were comparable to regular healthcare providers, demonstrating why some participants felt that IPs were undervalued and drawing reasonable attention to why they were fearful of others’ expectations after qualifying.

These results are reasonable given that others have proposed that self-efficacy related to SCT is based on the observations of others, exemplifying that observing effective or failed performances can enhance or decrease an observer’s self-efficacy (Schunk and DiBenedetto, 2020). In accordance with the results of the current study, another study using a qualitative interview approach to explore the experiences of secondary care nurse prescribers in the UK found that only three of the six prescribers were practising prescribing; the remainder did not use their IP qualifications (Scrafton et al, 2012).

‘A significant finding of the current study was that work settings were found to have a direct relationship with participants’ intentions to become independent prescribers ’

Similar research aimed at exploring an overview of non-medical prescribing in one strategic health authority found that 133 prescribers out of 883 (15.1%) were not using their prescribing qualifications (Courtenay et al, 2012). They argued that the lack of prescribing practice among NMPs could be reflected in wasted training time and expenses (Courtenay et al, 2012). This discrepancy in the IPs’ performance could account for the participants’ disappointment with those who hid their prescribing qualifications, which might be an important issue for future research.

Under the optimism theme, breadth of experience was associated with participants’ confidence and willingness to become IPs. Other authors have argued that, even for an experienced prescriber, prescribing is considered a challenging task that ultimately requires experience on top of practical skills, knowledge of medicines, and the comprehension of clinical pharmacology (Likic and Maxwell, 2009). This is in keeping with a previous study, which emphasised that doctors cited discomfort when prescribing medication without prior experience, even though evidence and literature were available to support its use (Lewis and Tully, 2009).

The findings of the current research support evidence from a systematic review, which identified the relationship between experience, confidence and professionalism when prescribing (Abuzour et al, 2018). Together with the current study’s outcomes, other studies have consistently referred to the concern described by participating nurses about safe prescribing due to insufficient experience or inadequate knowledge related to their prescribing boundaries (Scrafton et al, 2012). This combination of findings provides some support for the conceptual need to enhance undergraduate students’ training to meet the required patient-focused exposure to become IPs.

These results raise intriguing questions about whether future pharmacists in the UK will have the confidence to practise prescribing from the point of registration, considering their limited experience compared to current NMPs. In future investigations, it might be possible to explore the prescribing behaviours and confidence of students undertaking new MPharm programmes who will prescribe from the point of registration.

A significant finding of the current study was that work settings were found to have a direct relationship with participants’ intentions to become IPs. This result was in agreement with other findings, which showed that pharmacists who worked in patient-centred settings were strongly influenced to adopt advanced prescribing and that the community setting does not facilitate practice prescribing due to time insufficiency and a lack of collaboration and clinical information (Makowsky et al, 2013). It is encouraging to compare the current study’s findings with a systematic review, which emphasised that the leading factor for non-medical prescribing errors was a lack of patient medical information available at the practice site (Tully et al, 2009).

These findings raise reasonable justifications for the impact of healthcare settings on NMPs’ prescribing behaviours. Thus, it can be suggested that improving the practice level of a site could enhance prescribing quality, which would perhaps improve pharmacists’ and nurses’ intentional behaviours to become prescribers.

Limitations

Given the geographic limitation of the sample, the findings may not be representative, considering the wide variation in scope of practice and the vast number of IP programmes in the UK. Consistent with qualitative research models, no new data pertinent to the theory-driven themes were found in the latter interviews suggesting data saturation, specifically with regard to the pharmacists who worked in the primary care sector (Braun and Clarke, 2021).

Due to difficulties recruiting a large number of nurses, it is not known whether more interviews with nurses would have suggested new data. In addition, a more extended recruitment period would have been required to recruit a heterogeneous sample from various cohorts. Although the participants were asked to arrange meetings at convenient times, many interviews took place in their workplaces, suggesting that time constraints might have affected the participants’ abilities to provide in-depth information about their intention to become IPs.

Conclusion

Independent prescribing has been introduced to answer patients’ demands for access to seamless medical services and to reduce ongoing pressures on healthcare facilities. The findings of this study suggest that becoming an independent prescriber requires more than a strong desire to be involved in the clinical role. A collaborative approach in the work environment and during IP programme practical hours should be considered to improve students’ learning experiences and enhance their intentions to become IPs.

This study’s findings complement the findings of earlier studies that confirmed the relationship between the breadth of experience and confidence in prescribing. Significant barriers are associated with implementing prescribing in community settings, drawing attention to the importance of improving the practice levels of the setting. This would enhance the status of prescribing and facilitate the transition of pharmacists and nurses to prescribers.

Key Points

• Attitude was found to be the most prominent theme in the literature; it determined how NMPs practise their role in primary and secondary care
• This combination of findings may indicate that participants with a stronger intention to become IPs are more likely to perform the role as intended
• Pharmacists and nurses believed that time constraints were the main barrier to becoming IPs
• The study results raise intriguing questions about whether future pharmacists in the UK will have the confidence to practise prescribing from the point of registration