Abstract

Pharmacist prescribing is a growing reality in some developed counties, with varied health systems. Understanding the contribution that this activity can offer in the healthcare process, and investigating its acceptance is of utmost importance for the countries that implement and regulate this type of system. This literature review aimed to design a state-of-the-art academic investigation on the perception, opinions, and attitudes in the context of pharmacist prescribing practices in countries that have adopted this system. To achieve this, the present study conducted an investigation of the Medline, Scopus, Embase, SciELO, and Lilacs databases, resulting in the selection of 17 studies. From the analysis of the articles, three categories of discussion arose: “understanding of the practice and perceived benefits”, “acceptance and adherence to the practice, and “hindrances to the practice”. The results showed varied acceptance and perceptions among the different publics, depending, among other questions, on the level of knowledge and experience of the patients and health professionals, on the profile of the pharmacists, or on the prescribing modality. This study highlights some challenges involved in the practice of pharmacist prescribing, and its findings can be useful in suggesting a means through which to strengthen the practice.

Key words:
Health care; Pharmacists; Medical prescriptions; Professional practice

Introduction

The functions and responsibilities of all health professionals underwent a major transformation in the beginning of the twenty-first century. In this context, what stands out is the implementation of pharmacist prescribing by non-medical healthcare professionals in many countries, including Australia, Canada, the United States (USA), New Zealand, and the United Kingdom (UK)¹1 Stewart D, Jebara T, Cunningham S, Awaisu A, Pallivalapila A, Maclure K. Future perspectives on nonmedical prescribing. Ther Adv Drug Saf 2017; 8(6):183-197., aimed at contributing to improvements in health care, providing safer and more efficient access to medicines, and optimizing the application of healthcare professionals’ skills²2 Hoti K, Hughes J, Sunderland B. An expanded prescribing role for pharmacists - an Australian perspective. Australas Med J 2011; 4(4):236-242.^,33 Mcintosh T, Munro K, Mclay J, Stewart D. A cross sectional survey of the views of newly registered pharmacists in Great Britain on their potential prescribing role: a cautious approach. Br J Clin Pharmacol 2012; 73(4):656-660..

Despite the diversity of prescribing models used in the different countries, in general, two modalities can be pointed out: dependent prescribing and independent prescribing. In the dependent prescribing, there is a prior diagnosis and a clinical handling plan, developed in collaboration with the patients and their doctors. In this, the pharmacist may select, monitor, modify, or discontinue the pharmacotherapy⁴4 Tonna AP, Stewart D, West B, Mccaig D. Pharmacist prescribing in the UK - a literature review of current practice and research. J Clin Pharm Ther 2007; 32(6):545-556.

5 Famiyeh IM, Mccarthy L. Pharmacist prescribing: a scoping review about the views and experiences of patients and the public. Res Social Adm Pharm 2017; 13(1):1-16.^-66 Zhou M, Desborough J, Parkinson A, Douglas K, McDonald D, Boom K. Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences. Int J Pharm Pract 2019; 27(6):479-489..

By contrast, in independent prescribing, the pharmacist is responsible for evaluating the patient, beginning the therapy, and managing the clinical outcomes. Faced with a patient who has already been diagnosed by a doctor or is undergoing treatment, the pharmacist decides, without the need for a collaborative agreement, on the renewal of the prescription, its adaptation, or the issuing of a new prescription. In any of these situations, the pharmacist follows a list of pre-defined medications that regulate their range for use in prescriptions⁵5 Famiyeh IM, Mccarthy L. Pharmacist prescribing: a scoping review about the views and experiences of patients and the public. Res Social Adm Pharm 2017; 13(1):1-16.^,77 Department of Health. Supplementary prescribing by nurses and pharmacists with the NHS in England: a guide for implementation. London: Department of Health; 2003..

The UK and Canada are the two most experienced countries in the practice of pharmacist prescribing. In the UK, dependent prescribing was introduced in 2003 and independent prescribing in 2006⁸8 Graham-Clarke E, Rushton A, Noblet T, Marriott J. Non-medical prescribing in the United Kingdom National Health Service: a systematic policy review. PLoS One 2019; 14(7):e0214630.. In this context, being a non-medical prescriber requires the acquisition of a professional title and demands training and validation⁹9 Courtenay M, Carey N, Stenner K. An overiew of non-medical prescribing across one strategic health authority: a questionnaire survey. BMC Health Serv Res 2012; 12:138..

The pharmacist in Canada is both dependent and independent, encompassing three execution modalities: 1) the continuation of existing prescriptions, 2) the adaptation of existing prescriptions, and 3) the issuing of new prescriptions. The possible modalities and the need for collaborative agreements vary according to the Canadian province¹⁰10 Law MR, Ma T, Fisher J, Sketris IS. Independent pharmacist prescribing in Canada. Can Pharm J (Ott) 2012; 145(1):17-23.^,1111 Bhatia S, Simpson SH, Bungard T. Provincial Comparison of Pharmacist Prescribing in Canada Using Alberta's Model as the Reference Point. Can J Hosp Pharm 2017; 70(5):349-357.. Today, in all of the 11 provinces of the country, it is possible to renew or modify prescriptions; in nine provinces, one can provide a substitution within the same therapeutic group, while in eight, pharmacists can provide new prescriptions for less severe disorders¹²12 Canadian Pharmacists Association. Pharmacists' Expanded Scope of Practice in Canada Province/Territory, 2021. [cited 2021 abr 22]. Available from: https://www.pharmacists.ca/ pharmacy-in-canada/scope-of-practice-canada/
https://www.pharmacists.ca/ pharmacy-in-... .

In the USA, 49 states currently allow the pharmacist to prescribe under the dependent prescribing model. The first state, Washington, implemented this system in 1979. In the USA, the authorization for the pharmacists to prescribe was set forth in the Collaborative Practice Agreement, defined as an independent prescriber¹³13 Adams AJ, Weaver KK. The continuum of pharmacist prescriptive authority. Ann Pharmacother 2016; 50(9):778-784.. Together with this scenario, states have regulated dependent prescribing, based on state Collaborative Practice Agreements, that is, without the need for prior doctor’s appointments¹⁴14 Rodriguez MI, McConnell KJ, Swartz J, Edelman AB. Pharmacist prescription of hormonal contraception in Oregon: Baseline knowledge and interest in provision. J Am Pharm Assoc (2003) 2016; 56(5):521-526..

In Israel, dependent and independent prescribing coexist, regulated, respectively, in 2014 and 2016¹⁵15 Yariv H. The case of pharmacist prescribing policy in Israel. Isr J Health Policy Res 2015; 4:49.. In Australia, pharmacists can only prescribe over-the-counter medications for specific health situations, minor disorders²2 Hoti K, Hughes J, Sunderland B. An expanded prescribing role for pharmacists - an Australian perspective. Australas Med J 2011; 4(4):236-242.. In New Zealand, pharmacist prescribing has been authorized since 2013, so long as it is dependent prescribing, with the pharmacist working in collaboration with other healthcare professionals¹⁶16 Jebara T, Cunningham S, MacLure K, Awaisu A, Pallivalapila A, Stewart D. Stakeholders' views and experiences of pharmacist prescribing: a systematic review. Br J Clin Pharmacol 2018; 84(9):1883-1905..

The expansion of prescriptions in all of the countries mentioned above has boosted academic production in countries in which there is still no regulation regarding pharmacist prescribing. Researchers, therefore, mobilize themselves to produce relevant information that can sustain the planning of the incorporation of this innovation, such as the expectations of the pharmacists and the identification of factors that can interfere in a possible implementation of the practice. In the literature, there are records of these studies, for example in Qatar¹⁷17 Diab MI, Ibrahim A, Abdallah O, El-Awaisi A, Zolezzi M, Ageeb RA, Elkhalifa WHI, Awaisu A. Perspectives of future pharmacists on the potential for development and implementation of pharmacist prescribing in Qatar. Int J Clin Pharm 2020; 42(1):110-123., Nigeria¹⁸18 Auta A, Strickland-Hodge B, Maz J, David S. Pharmacist prescribing: a cross-sectional survey of the views of pharmacists in Nigeria. Int J Pharm Pract 2018; 26(2):111-119., and Malta¹⁹19 Aquilina A, Wirth F, Pizzuto MA, Grech L, Camilleri L, Azzopardi LM, Serracino-Inglott A. Preparing for pharmacist prescribing in Maltese hospitals. J Pharm Health Serv Res 2018; 9(3):237-243..

All changes require observation and analysis. Pharmacist prescribing in Brazil was recently regulated and can still be considered an innovation in professional practice, since it dates back to 2013. Stewart et al.¹1 Stewart D, Jebara T, Cunningham S, Awaisu A, Pallivalapila A, Maclure K. Future perspectives on nonmedical prescribing. Ther Adv Drug Saf 2017; 8(6):183-197. consider that two questions are crucial in the implementation of new practices of non-medical prescribing: development of sustainable models of health care, as well as robust and strict evaluative research.

In this light, understanding state-of-the-art pharmacist prescribing in the world makes it necessary to subsidize the planning and evaluation of health policies and interventions in Brazil. Faced with this scenario, the present study, through a literature review, aimed to explore the perception, opinions, and attitudes of patients, the general population, healthcare professionals, and pharmacists regarding pharmacist prescribing.

Methodology

The present study is a literature review about pharmacist prescribing in countries that have adopted this system, developed through the systematic selection of scientific literature.

The guiding question that characterizes the first stage of this study was: What is the perception, experience, and reception of pharmacist prescribing practices by any group of the interested parties (pharmacists, other health professionals, patients, health managers, and society in general)?

In the subsequent stage, the following databases were defined to conduct the search for articles: MEDLINE (National Library of Medicine); Scopus; Embase; SciELO (Scientific Electronic Library Online); and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde). The survey was carried out in June 2020 and was adjusted according to the following filters: period of publication in the last ten years and the English, Spanish, or Portuguese languages.

To conduct the search for articles, this study used free terms and their combinations in three languages treated in this literature review, given that the terms indexed in the Health Sciences Descriptors and in the Medical Subject Headings (MESH) did not contemplate the aim of the present study.

In the search, the descriptors were used together with the aid of the Boolean operator OR, resulting in the following combination: “prescri* farmacêutic*” OR “prescri* colaborativ*” OR “prescri* suplementar” OR “prescri* independente” OR “prescri* não-médica”. For the databases of Medline, Scopus, and Embase, terms in English were used (“pharmacist prescri*” OR “collaborative prescri*” OR “supplementary prescri*” OR “independent prescri*” OR “non-medical prescri*”). For the Scielo and Lilacs databases, terms in the English, Portuguese, and Spanish languages were used. The Lilacs database was accessed through the Virtual Health Library (BVS, in Portuguese). The character “*” was used at the end of some terms to increase its reach, including different terminologies, such as prescrição and prescritor, in addition to synonyms for the same terms in English, such as prescription and prescribing.

Since the Lilacs and Scielo databases did not present results, a new search was conducted, only in these two databases, with the simple combination of the terms “prescribing” AND “pharmacist”, in the English, Portuguese, and Spanish languages.

The combination of the terms, as well as the results found for each electronic database platform, are presented in detail in Chart 1.

Selection criteria were applied in an attempt to achieve the objectives of this study. The inclusion criteria for the selection of material were: 1) publication within the last ten years, from June 2010 to June 2020; 2) articles in the English, Portuguese, and Spanish languages; and 3) available as a full text in one of the databases used in this study, through the researcher’s institutional network access. The exclusion criteria adopted to the studies were: 1) the space for healthcare practices of the subjects studied in this work, when applicable, were exclusively or to a great extent in a hospital environment; 2) the study is related only to the teaching of skills and attributes of non-medical prescribing; 3) the study involved participants that are only undergraduate students or the majority were made up of non-pharmaceutical health professionals; 4) review article, editorial, opinion article, report, letter or free communication, book chapters, or event abstracts; and 5) articles that deviated from the intended theme of the scope of the present study.

The article selection process, which begins with the exporting of results from the databases, was performed using the Zotero software. The stages that followed in this process were the exclusion of duplicate articles and the judgement of the studies, observing if they were adequate to the inclusion and exclusion criteria and if they met the objectives of the present study. The layout of the article selection process is presented in Figure 1.

To characterize the selected publications for this literature review, the following variables were extracted: main author, year of publication, location of study, objectives, methodology, participants of the study, prescription modality, study limitations, and conclusions.

For the qualitative analysis of the content, the reading, analysis, and interpretation of each article were performed, using the Thematic Content Analysis, proposed by Minayo²⁰20 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2014., which carries out the exploration of the material in a systematic manner, aimed at achieving the subjective interpretation of the texts and the presentation of the finding in an organized and categorized manner. The process of analysis enabled its classification in three empirical categories: Understanding of the practice and perceived benefits, acceptance and adherence to the practice, and hindrances to the practice.

Results

The search in all of the databases found a total of 2,818 publications. When all of the selection stages had been concluded, the final number was 17 articles included in this literature review. Some publication variables, which characterize the articles, were organized in charts 2 and 3.

Most of the studies were published in 2013 (23%), 2015 (18%), and 2019 (18%). As regards the prescription model, 18% of the studies were only about the dependent prescribing, 23% only about the independent prescribing, and 59% made no distinction, including both models. The analyzed studies were developed about the contexts of the following locations: the UK (41.2%), Canada (47.0%), and the US (11.8%).

As of the analysis of the selected material, empirical categories were formed: understanding of the practice and perceived benefits, acceptance and adherence to the practice, and hindrances to the practice.

Understanding of the practice and perceived benefits

The studies analyzed in this literature review, in general, demonstrated that the users of healthcare services have little knowledge about pharmacist prescribing, with few having already experienced a care accompanied by the prescription by this professional²¹21 Famiyeh IM, Mackeigan L, Thompson A, Kuluski K, Mccarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Social Adm Pharm 2019; 15(5):575-583.

22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461.^-2323 Hobson RJ, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient's perspective. Fam Pract 2010; 27(1):110-120.^,3131 Mccann LM, Haughey SL, ParSONS C, Lloyd F, Crealey G, Gormley GJ, HugheS CM. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect 2015; 18(1):58-68.. The users tend to make positive observations about the traditional functions of the pharmacist, valuing their advice²³23 Hobson RJ, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient's perspective. Fam Pract 2010; 27(1):110-120.; however, they tend not to recognize the possibilities involved in pharmacist prescribing and distrust their execution²²22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461..

Despite the lack of user knowledge regarding pharmacist prescribing²¹21 Famiyeh IM, Mackeigan L, Thompson A, Kuluski K, Mccarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Social Adm Pharm 2019; 15(5):575-583.

22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461.^-2323 Hobson RJ, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient's perspective. Fam Pract 2010; 27(1):110-120.^,3131 Mccann LM, Haughey SL, ParSONS C, Lloyd F, Crealey G, Gormley GJ, HugheS CM. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect 2015; 18(1):58-68., they stand out in relation to the possible prescriptions issued by non-medical professionals. In Scotland, although various professionals are authorized to prescribe, pharmacist prescribing is more well-accepted by the population and a synonym of non-medical prescribing³²32 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):704-710..

This situation of unfamiliarity can change when users go through the experience of receiving a prescription from a pharmacist, as shown in a study from the UK³¹31 Mccann LM, Haughey SL, ParSONS C, Lloyd F, Crealey G, Gormley GJ, HugheS CM. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect 2015; 18(1):58-68.. In this study, the users found advantages in pharmacist prescribing, since they considered that the pharmacists had a greater knowledge about medicines, interactions, and side effects than did doctors in general. They recognized that health professionals should use their own professional skills in a complementary fashion: diagnosis (doctor) and management of the drug therapy (pharmacist).

In addition, the users highlighted as advantages: the increase in time for doctor´s appointments, in-depth information provided about their medicines, and a better feeling of the control and comprehension of their medical condition³¹31 Mccann LM, Haughey SL, ParSONS C, Lloyd F, Crealey G, Gormley GJ, HugheS CM. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect 2015; 18(1):58-68.. In a probable implementation of the work of a prescribing pharmacist in a nursing home in the UK, the patients saw the insertion as a very positive proposal, acting as a necessary and useful channel of opportune and reassuring communication about medicines²⁷27 Lane K, Bond C, Wright D, Alldred DP, Desborough J, Holland R, Hughes C, Poland F. "Everyone needs to understand each other's systems": stakeholder views on the acceptability and viability of a Pharmacist Independent Prescriber role in care homes for older people in the UK. Health Soc Care Community 2020; 28(5):1479-1487..

For the population in general, the practice brings individual and collective benefits. Individual, as they witnessed the convenience of needing less doctor’s appointments, and collective, as they saw benefits for the health system, such as the reduction in the doctors’ workload and, consequently, a greater focus of these doctors on patients with more complex needs²¹21 Famiyeh IM, Mackeigan L, Thompson A, Kuluski K, Mccarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Social Adm Pharm 2019; 15(5):575-583.^,3232 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):704-710.. Other advantages were that the prescription acquired could include the change in the current doctors’ prescriptions in the case of adverse effects or the independent prescribing in clear situations of the need for urgent care or in prescribing for less complex diseases²²22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461.. The increase in the access to medicines in a situation in which there was a hindrance to the access to medical services, or personal demands that made the search for a doctor difficult, were also pointed out as clear benefits²⁵25 Irwin AN, Stewart OC, Nguyen VQ, Bzowyckyj AS. Public perception of pharmacist-prescribed self-administered non-emergency hormonal contraception: an analysis of online social discourse. Res Social Adm Pharm 2019; 15(6):650-655..

The benefits of the practice can also be perceived by health professionals. For pharmacists, the prescription would provide greater access of the patients to essential medications, diminish the costs for patients, promote patient comfort, and reduce the burden on the health system²²22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461.^,3434 Norman WV, Soon JA, Panagiotoglou D, Albert A, Zed PJ. The acceptability of contraception task-sharing among pharmacists in Canada - the ACT-Pharm study. Contraception 2015; 92(1):55-61..

In one study conducted in a Canadian province³⁵35 Pojskic N, Mackeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists. Res Social Adm Pharm 2014; 10(2):341-354., with professionals from the associations of pharmacists and local managers, these professionals pointed out the many benefits within the proposal for the implementation of independent prescribing in the province: the increase in patient access to primary health care; improvements in patient results through improvements in the continuity of drug therapy; reductions in side effects to medicines; and the diminishing of healthcare costs by redirectioning less expensive healthcare costs to the health professionals.

British and Canadian doctors saw, with the incorporation of a prescribing pharmacist in work teams, the following advantages: collaboration in the division of the workload and responsibilities, allowing the pharmacist to fill a gap in activities in which the doctor was unable to dedicate him/herself fully to the exercising of multiple tasks; the review of pharmacotherapy; and the management of drug therapy²⁸28 Lloyd F, Parsons C, Hughes CM. 'It's showed me the skills that he has': pharmacists' and mentors' views on pharmacist supplementary prescribing. Int J Pharm Pract 2010; 18(1):29-36.. In another study, in the UK, the inclusion of pharmacist prescribing, in a nursing home, was seen by doctors and pharmacists as capable of contributing to combatting chronic diseases, in which the reviews of pharmacotherapies are complex due to the multiple comorbidities of the residents²⁷27 Lane K, Bond C, Wright D, Alldred DP, Desborough J, Holland R, Hughes C, Poland F. "Everyone needs to understand each other's systems": stakeholder views on the acceptability and viability of a Pharmacist Independent Prescriber role in care homes for older people in the UK. Health Soc Care Community 2020; 28(5):1479-1487..

In another study conducted with British doctors, the pharmacists were especially useful for patients with multiple morbidities, as their education in pharmacology enabled them to have a broader overview of the patient. The pharmacist’s general knowledge of medicine was seen as an advantage because of their attention to detail. In this sense, pharmacist prescribing was deemed to be safe³²32 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):704-710..

Acceptance and adherence to the practice

The patients suggested that an increase in the popularity of the pharmacist prescribing among the population would be directly linked to the time that it would take for the patients to construct an image of a relationship with this prescribing pharmacist²³23 Hobson RJ, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient's perspective. Fam Pract 2010; 27(1):110-120., as well as with other prescribing professionals, such as the nurses, who, according to the authors, are more well-accepted by the population due to their practice of prescribing medicines, as they are more well-known for the health care they provide.

From the pharmacists’ point of view, doctors and nurses consider pharmacist prescribing in a collaborative institutional environment to be positive, since, in this sense, they can divide the workload, allowing them to concentrate on other clinical tasks²⁸28 Lloyd F, Parsons C, Hughes CM. 'It's showed me the skills that he has': pharmacists' and mentors' views on pharmacist supplementary prescribing. Int J Pharm Pract 2010; 18(1):29-36.. The pharmacists believe that the doctors are more receptive if the pharmacist prescribing is done within a limited scope²²22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461..

There is still a certain fear on the part of society concerning the prescribing functions of a pharmacist, with varying support. The majority of the target public in a study conducted by Maclure et al.³²32 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):704-710., consisting of citizens, would suggest that pharmacists should only to prescribe for less complex diseases or medications considered to be low risk, within their competency, and appropriate for their field of practice. However, the authors also noted in participants’ answers that having had a prior experience with pharmacists or having a reliable pharmacist, made them more receptive to pharmacist prescribing.

When doctors and pharmacists seem to disagree about the prescribing role of the pharmacist, the discourse about the safety of the patient is generally the main point of conflicting opinions. This disagreement tends to occur in relation to independent prescribing. While doctors claimed that pharmacist prescribing means a danger to the patients, the pharmacists also questioned the safety of medical prescribing, given the magnitude of the problems related to the medicines that occur in locations without pharmacist prescribing. They also argue that, rather than cause damage, the pharmacist prescribing would increase patient safety due to the more proactive involvement of the pharmacist in the management of the patient’s drug therapy³⁵35 Pojskic N, Mackeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists. Res Social Adm Pharm 2014; 10(2):341-354.^,3636 Schindel TJ, Given LM. The pharmacist as prescriber: a discourse analysis of newspaper media in Canada. Res Social Adm Pharm 2013; 9(4):384-395..

It was also notable in the studies that the pharmacists have a very clear notion of responsibility when prescribing medicine. This can often generate a certain fear among pharmacists of prescribing, but this dissipated over time with experience. This also contributed so that they could make a proper documentation of the prescribing process and could expand the time and care provided to other traditional functions, such as the review of the clinical situation of the patients and the monitoring of pharmacotherapy²⁴24 Hughes CA, Makowsky M, Sadowski CA, Schindel TJ, Yuksel N, Guirguis LM. What prescribing means to pharmacists: a qualitative exploration of practising pharmacists in Alberta. Int J Pharm Pract 2014; 22(4):283-291.^,2929 Makowsky MJ, Guirguis LM, Hughes CA, Sadowski CA, Yuksel N. Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory. Implement Sci 2013; 8:109.. The pharmacists also give value to prescribing within the context of an interdisciplinary team for the management of patients with long-term conditions and multimorbidities, since this would bring different advantages to the prescribing exercise, resulting in a better and more effective patient care³⁰30 Mccann L, Lloyd F, Parsons C, Gormley G, Haughey S, Crealey G, Hughes C. "They come with multiple morbidities": a qualitative assessment of pharmacist prescribing. J Interprof Care 2012; 26(2):127-133..

One study conducted with Canadian pharmacists pointed out that, even the conceptions that pharmacists have of prescribing practices impact the adherence to this activity. Those that brought a more integrated definition of the prescription to the healthcare process generally showed a greater initiative toward independent prescribing²⁴24 Hughes CA, Makowsky M, Sadowski CA, Schindel TJ, Yuksel N, Guirguis LM. What prescribing means to pharmacists: a qualitative exploration of practising pharmacists in Alberta. Int J Pharm Pract 2014; 22(4):283-291..

In the study conducted by Makowsky et al.²⁹29 Makowsky MJ, Guirguis LM, Hughes CA, Sadowski CA, Yuksel N. Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory. Implement Sci 2013; 8:109., the pharmacists who thought that there were few advantages in prescribing were less prone to prescribe or to obtain authorization to prescribe, much like those who did not believe that prescribing was a part of their professional role. The authors also observed that the pharmacists were less prone to prescribe in more complex situations in which the patient used various medicines, had an unclear diagnosis, or did not fit within the typical clinical guidelines. By contrast, in situations in which the pharmacist felt that he/she had command of the problem, the intention to prescribe was greater. When the pharmacists had a habit of prescribing, they mentioned the advantages of prescribing for their professional practice, such as an increase in their sense of professionalism, improvement in their self-image as a health professional, and their own work satisfaction.

The field of practice and the prescribing modality produce different impacts on the adoption of pharmacist prescribing. In a longitudinal study conducted in the UK with pharmacists, one year after receiving the authorization to prescribe, only 25% of these professionals actively prescribed, and they performed this act mainly within hospitals, with little or no activity in other environments, following primarily the dependent prescribing modality²⁸28 Lloyd F, Parsons C, Hughes CM. 'It's showed me the skills that he has': pharmacists' and mentors' views on pharmacist supplementary prescribing. Int J Pharm Pract 2010; 18(1):29-36..

Hindrances to the practice

In the studies selected for this literature review, the patients voiced some fears about pharmacist prescribing: they would approve this type of prescription only in less complex cases²³23 Hobson RJ, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient's perspective. Fam Pract 2010; 27(1):110-120., or chronic conditions, in which there was a certain control²¹21 Famiyeh IM, Mackeigan L, Thompson A, Kuluski K, Mccarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Social Adm Pharm 2019; 15(5):575-583., or areas of pre-determined work³¹31 Mccann LM, Haughey SL, ParSONS C, Lloyd F, Crealey G, Gormley GJ, HugheS CM. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect 2015; 18(1):58-68.. They tended to be leery that pharmacists would not have access to the necessary clinical information from medical records to make a proper evaluation²¹21 Famiyeh IM, Mackeigan L, Thompson A, Kuluski K, Mccarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Social Adm Pharm 2019; 15(5):575-583., or were even worried about the confidentiality of the data²³23 Hobson RJ, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient's perspective. Fam Pract 2010; 27(1):110-120..

Studies with pharmacists have shown that these professionals have a major interest in prescribing practices, but they claim, as hindrances to the practice, a need for better training, the acquisition of knowledge, and the development of skills²²22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461.^,2626 Isenor JE, Minard LV, Stewart SA, Curran JA, Deal H, Rodrigues G, Sketris IS. Identification of the relationship between barriers and facilitators of pharmacist prescribing and self-reported prescribing activity using the theoretical domains framework. Res Social Adm Pharm 2018; 14(8):784-791.^,2929 Makowsky MJ, Guirguis LM, Hughes CA, Sadowski CA, Yuksel N. Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory. Implement Sci 2013; 8:109.^,3737 Schindel TJ, Yuksel N, Breault R, Daniels J, Varnhagen S, Hughes CA. Pharmacists' learning needs in the era of expanding scopes of practice: evolving practices and changing needs, Res Social Adm Pharm 2019; 15(4):448-458.. This need may not seem to be homogenous, as it depended on the profile of the pharmacist in relation to the number of years in the practice, the environment of the practice (community or hospital), prior education, and status of authorization for additional prescribing³⁷37 Schindel TJ, Yuksel N, Breault R, Daniels J, Varnhagen S, Hughes CA. Pharmacists' learning needs in the era of expanding scopes of practice: evolving practices and changing needs, Res Social Adm Pharm 2019; 15(4):448-458.. In this Canadian study, the authors noted that pharmacists with extensive experience (over 20 years) and in a non-collaborative work environment (community pharmacy) reported the need for additional training more emphatically.

Pharmacists from the UK who are recent graduates and are still without proper registration and training expressed their concern about their own competence to prescribe, highlighting the lack of diagnostic skills, feeling more comfortable with dependent prescribing, which requires an agreement with a doctor³³33 Mcintosh T, Stewart D. A qualitative study of UK pharmacy pre-registration graduates' views and reflections on pharmacist prescribing. Int J Pharm Pract 2016; 24(2):139-141..

The lack of an organizational strategy that encourages pharmacist prescribing, the fear of an increase in responsibility and an increase in workload were pointed out by the pharmacists as hindrances to their beginning to prescribe. Add to these factors the lack of specific financing for the activity, the bureaucracy involving the clinical management plan, the lack of governmental support from regional health clinics, and the reluctance to create incentives for the practice. Another important point cited was the lack of general knowledge of other health professionals about the practice itself²⁸28 Lloyd F, Parsons C, Hughes CM. 'It's showed me the skills that he has': pharmacists' and mentors' views on pharmacist supplementary prescribing. Int J Pharm Pract 2010; 18(1):29-36.^,3333 Mcintosh T, Stewart D. A qualitative study of UK pharmacy pre-registration graduates' views and reflections on pharmacist prescribing. Int J Pharm Pract 2016; 24(2):139-141..

In a study conducted by Feehan et al.²²22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461., the pharmacists who had no interest in prescribing pointed to the lack of training added to the concern over the reaction of doctors and other healthcare professionals, who may not be receptive to the practice, seeing pharmacist prescribing as a threat to their business and, subtly, to their professional position.

For the pharmacists, the lack of a teamwork environment presented a hindrance to prescribing. In one study with pharmacists who had recently been authorized to prescribe²⁸28 Lloyd F, Parsons C, Hughes CM. 'It's showed me the skills that he has': pharmacists' and mentors' views on pharmacist supplementary prescribing. Int J Pharm Pract 2010; 18(1):29-36., the subjects believed that the hospital pharmacists were in an ideal position to provide dependent prescribing and saw difficulties in prescribing in the community pharmacy practice, mainly due to the natural distance of the independent prescriber and due to the easier access to patient records in the hospital environment.

Knowledge about the regulation of prescribing is highly relevant for the adoption of this practice. In Canada, as it is necessary to obtain an authorization for independent prescribing in most provinces, it is crucial that the pharmacist understand the conditions necessary to obtain it. Nevertheless, studies have observed that the majority of pharmacists were unaware of certain prerequisites needed to obtain the authorization to prescribe or were unaware of the possible prescribing practices²⁴24 Hughes CA, Makowsky M, Sadowski CA, Schindel TJ, Yuksel N, Guirguis LM. What prescribing means to pharmacists: a qualitative exploration of practising pharmacists in Alberta. Int J Pharm Pract 2014; 22(4):283-291.^,2929 Makowsky MJ, Guirguis LM, Hughes CA, Sadowski CA, Yuksel N. Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory. Implement Sci 2013; 8:109..

Discussion

This is the first literature review worldwide, originally written in Portuguese, about pharmacist prescribing. In this review, the experiences and viewpoints were explored, as well as the opinions of the general public, pharmacists, doctors, and other interested parties in relation to pharmacist prescribing, presenting an exploratory character about the acceptance of pharmacist prescribing for distinct publics.

Other reviews have been published in other languages on the same subject⁵5 Famiyeh IM, Mccarthy L. Pharmacist prescribing: a scoping review about the views and experiences of patients and the public. Res Social Adm Pharm 2017; 13(1):1-16.^,66 Zhou M, Desborough J, Parkinson A, Douglas K, McDonald D, Boom K. Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences. Int J Pharm Pract 2019; 27(6):479-489.^,1616 Jebara T, Cunningham S, MacLure K, Awaisu A, Pallivalapila A, Stewart D. Stakeholders' views and experiences of pharmacist prescribing: a systematic review. Br J Clin Pharmacol 2018; 84(9):1883-1905.^,3838 Cope LC, Abuzour AS, Tully MP. Nonmedical prescribing: where are we now? Ther Adv Drug Saf 2016; 7(4):165-172.

39 Noblet T, Marriott J, Graham-Clarke E, Rushton A. Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review. J Physiother 2017; 63(4):221-234.^-4040 Graham-Clarke E, Rushton A, Noblet T, Marriott J. Facilitators and barriers to non-medical prescribing - a systematic review and thematic synthesis. PLoS One 2018; 13(4):e0196471.. These revisions, in general, noted that the hindrances for the implementation of non-medical prescribing practices (including pharmacist) are multifactorial and that the practice should be successful and should involve all of the interested parties in a coordinated approach. Personal questions, to understand what the professional’s “area of competency” was and to see the relationship between the health professionals were relevant for the prescriptions to be issued. Moreover, the impact of the prescribing activity in the opinions and results of the patients, as well as in the opinions of the doctors and other health professionals, was generally positive.

One can consider that the literature that treats the subject is still limited to the countries that have regulated pharmacist prescribing some time ago and that have a greater variety of practices, such as the UK and Canada. In Canada, the possibilities of pharmacist prescribing differ by province, and this was reflected in the results with the larger number of studies conducted in the province of Alberta, where the practice is more advanced.

This literature review did not identify articles published with Brazilian experiences on the issue. This absence is an important finding that indicates that the academic production in Brazil in this area is still incipient, which most likely reflects an unconsolidated practice of pharmacist prescribing in the country. These affirmations are even more consistent when the authors, experimentally (outside of the data collection presented here), increased the range of research (gray literature) in order to search for articles that include Brazilian experiences, an action which was also unsuccessful. The absence of studies about this practice in Brazil shows the need for incentives for further research and make the understanding of the practice in other countries a possible path through which to explore the theme.

This literature review noted that the patients and the public in general (non-patients) tend to express different views about the expansion of pharmacist prescribing practices²¹21 Famiyeh IM, Mackeigan L, Thompson A, Kuluski K, Mccarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Social Adm Pharm 2019; 15(5):575-583.

22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461.^-2323 Hobson RJ, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient's perspective. Fam Pract 2010; 27(1):110-120.^,2525 Irwin AN, Stewart OC, Nguyen VQ, Bzowyckyj AS. Public perception of pharmacist-prescribed self-administered non-emergency hormonal contraception: an analysis of online social discourse. Res Social Adm Pharm 2019; 15(6):650-655.^,2727 Lane K, Bond C, Wright D, Alldred DP, Desborough J, Holland R, Hughes C, Poland F. "Everyone needs to understand each other's systems": stakeholder views on the acceptability and viability of a Pharmacist Independent Prescriber role in care homes for older people in the UK. Health Soc Care Community 2020; 28(5):1479-1487.^,3131 Mccann LM, Haughey SL, ParSONS C, Lloyd F, Crealey G, Gormley GJ, HugheS CM. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect 2015; 18(1):58-68.^,3232 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):704-710.. In general, they are in favor of prescribing, but they are leery about the limits of the practice, and often do not understand how the pharmacist prescribing is done and how pharmacists are trained to perform this act²¹21 Famiyeh IM, Mackeigan L, Thompson A, Kuluski K, Mccarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Social Adm Pharm 2019; 15(5):575-583.

22 Feehan M, Durante R, Ruble J, Munger MA. Qualitative interviews regarding pharmacist prescribing in the community setting. Am J Health Syst Pharm 2016; 73(18):1456-1461.^-2323 Hobson RJ, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient's perspective. Fam Pract 2010; 27(1):110-120.^,2525 Irwin AN, Stewart OC, Nguyen VQ, Bzowyckyj AS. Public perception of pharmacist-prescribed self-administered non-emergency hormonal contraception: an analysis of online social discourse. Res Social Adm Pharm 2019; 15(6):650-655.^,2727 Lane K, Bond C, Wright D, Alldred DP, Desborough J, Holland R, Hughes C, Poland F. "Everyone needs to understand each other's systems": stakeholder views on the acceptability and viability of a Pharmacist Independent Prescriber role in care homes for older people in the UK. Health Soc Care Community 2020; 28(5):1479-1487.^,3131 Mccann LM, Haughey SL, ParSONS C, Lloyd F, Crealey G, Gormley GJ, HugheS CM. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect 2015; 18(1):58-68.^,3232 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):704-710.. It was noted that much of the lack of knowledge regarding the practice came from their lack of experience regarding this type of service with the pharmacist³¹31 Mccann LM, Haughey SL, ParSONS C, Lloyd F, Crealey G, Gormley GJ, HugheS CM. A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'. Health Expect 2015; 18(1):58-68.^,3232 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):704-710..

The process of consolidation of new professional practices may well be time-consuming. The pharmaceutical profession in the world has undergone a deep historical transformation. As of the expansion of the industrialization of medicines, the traditional function of producing the medicine for the patients has practically disappeared and the pharmacist has been forced to find another model of community-based pharmacy practice. This new and necessary direction of the pharmaceutical practice was slow to take place, but today it is firm in the proposal to treat the patient as the main focus, in an effort to provide the patient with satisfactory health results, in turn improving their quality of life⁴¹41 Pereira LRL, Freitas O. A evolução da atenção farmacêutica e a perspectiva para o Brasil. Rev Bras Cienc Farm 2008; 44(4):601-612.^,4242 Pereira ML, Nascimento MMG. Das boticas aos cuidados farmacêuticos: perspectivas do profissional farmacêutico. Rev Bras Farm 2011; 92(4): 245-252.. In the Brazilian context, where the demands for health care are not fully met and the community-based pharmacy ends up occupying the place as a health establishment that is more accessible to the population, self-medication and therapeutic recommendations have become commonplace practices⁴³43 Naves JOS, Castro LLC, Carvalho CMS, Merchán-Hamann E. Automedicação: uma abordagem qualitativa de suas motivações. Cien Saude Colet 2010;15(1):1751-1762.. A transition from one scenario of self-medication and the informal medical recommendations by the clerks and pharmacists for a documented and professional practice of pharmacist prescribing represents a goal set by the regulation of pharmacist prescribing in Brazil, under resolution CFF 586/13⁴⁴44 Conselho Federal de Farmácia. Resolução nº 586 de 29 de agosto de 2013. Regula a prescrição farmacêutica e dá outras providências. Diário Oficial da União 2013; 26 set..

In the present study, patients and the public in general tended to show greater support when they had a history of care with the pharmacist prescriber. The perception of this public was that the pharmacists provide more detailed information; they are accessible and didactic; they invest their time to determine the best treatment and drug safety; and they are open to give a more detailed explanation about their medical condition²¹21 Famiyeh IM, Mackeigan L, Thompson A, Kuluski K, Mccarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Social Adm Pharm 2019; 15(5):575-583.. Other reviews have also found positive viewpoints and experiences from the same group of subjects interested in this research regarding pharmacist prescribing, listing the following positive points: easier access to the pharmacist; better results for the patient; better use of the skills and knowledge of the pharmacists; good communication with the prescribing pharmacist; and the reduction in the doctor’s workload⁵5 Famiyeh IM, Mccarthy L. Pharmacist prescribing: a scoping review about the views and experiences of patients and the public. Res Social Adm Pharm 2017; 13(1):1-16.^,1616 Jebara T, Cunningham S, MacLure K, Awaisu A, Pallivalapila A, Stewart D. Stakeholders' views and experiences of pharmacist prescribing: a systematic review. Br J Clin Pharmacol 2018; 84(9):1883-1905..

Regarding the adherence of the pharmacist to prescribing, what was found in this review was that it was not homogeneous, as it was related to the perception that this professional has of the prescribing activity itself, of the perception of the pharmacist’s role, of the demands that they believe pharmacists should have in order to prescribe, and of the work environment where this is implemented.

For Hughes et al.²⁴24 Hughes CA, Makowsky M, Sadowski CA, Schindel TJ, Yuksel N, Guirguis LM. What prescribing means to pharmacists: a qualitative exploration of practising pharmacists in Alberta. Int J Pharm Pract 2014; 22(4):283-291., the concept of the pharmacist prescribing is relatively new and may require a redefinition of the professional identify. Thus, as more pharmacists expand their practices within the context of legal structures, it is quite possible that their views about prescriptions and professional identities may also evolve.

Hindrances related to the work environment (adequate time, pharmacy structure, guarantee of privacy, and access to data), regulation (concerns related to responsibility), and support provided to other professionals (pharmacist-doctor relationship) were present. Similar hindrances were also identified in a review conducted by Zhou et al⁶6 Zhou M, Desborough J, Parkinson A, Douglas K, McDonald D, Boom K. Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences. Int J Pharm Pract 2019; 27(6):479-489..

Despite these hindrances, pharmacists, when prescribing, saw highly positive results for their own professional satisfaction, for the quality of pharmacist-patient relationship, and for improvements in health care. For Lloyd et al.²⁸28 Lloyd F, Parsons C, Hughes CM. 'It's showed me the skills that he has': pharmacists' and mentors' views on pharmacist supplementary prescribing. Int J Pharm Pract 2010; 18(1):29-36., prescribing generates a transformation in the confidence of the pharmacist and in their contact with the patient, with improvements seen in the continuity, quality, and safety of the care provided.

The investigation of hindrances to the execution of an innovative practice in a traditional profession is essential in order to break new ground for incentives to this practice. As argues Batra et al.⁴⁵45 Batra P, Rafie S, Zhang Z, Singh AV, Bird CE, Sridhar A, Sullivan JG. An evaluation of the implementation of pharmacist-prescribed hormonal contraceptives in California. Obstet Gynecol 2018; 131(5):850-855., a single legal change may not be sufficient to change the practice effectively and quickly. Therefore, it is necessary to understand the particularities of adherence to the practice so as to design strategies to overcome these barriers.

Regarding the environment of the prescribing practice, this study observed that, in those locations in which the pharmacist works in partnership with other health professionals, especially doctors, pharmacist prescribing takes place more fluidly, generally in a collaborative manner. By contrast, the pharmacists who work independently tend to feel greater difficulties and apprehension in prescribing. For Weiss and Sutton⁴⁶46 Weiss MC, Sutton J. The changing nature of prescribing: pharmacists as prescribers and challenges to medical dominance. Sociol Health Illn 2009; 31(3):406-421., even with the authorization to prescribe, pharmacists can see themselves as subordinate within a hierarchy dominated by the medical field, seeking an approval from the doctor before prescribing.

It was common for pharmacists to demand further training and qualification, be it to begin to prescribe or to prescribe independently. When the participants felt that they had the necessary skills to conduct the activity, they were more prone to put it into practice.

The results showing the apprehension of pharmacists to begin to prescribe²⁶26 Isenor JE, Minard LV, Stewart SA, Curran JA, Deal H, Rodrigues G, Sketris IS. Identification of the relationship between barriers and facilitators of pharmacist prescribing and self-reported prescribing activity using the theoretical domains framework. Res Social Adm Pharm 2018; 14(8):784-791.^,3333 Mcintosh T, Stewart D. A qualitative study of UK pharmacy pre-registration graduates' views and reflections on pharmacist prescribing. Int J Pharm Pract 2016; 24(2):139-141. should serve as a warning for the reorganization of educational programs for undergraduate pharmacy students. It is necessary that these programs prepare the pharmacist with clinical and managerial skills that provide them with the proper qualification in order to propose the implementation of new pharmacist prescribing services at the level of prescribing within the organizations in which they work. Pharmacists engaged in applying their knowledge and skills will enhance support provided to society, as well as from other health professionals and pharmacists to the prescribing activity.

McIntosh et al.³³33 Mcintosh T, Stewart D. A qualitative study of UK pharmacy pre-registration graduates' views and reflections on pharmacist prescribing. Int J Pharm Pract 2016; 24(2):139-141., observing the scenario in the UK, suggest, as a probable path, a review of the education of pharmacists and of the pre-registration training for a possible integrated program that leads to undergraduate studies and registration, promoting a contextualization of the learning process in a more clinically focused manner.

In the USA, where prescribing is mostly dependent, the expansion of prescriptions has taken off, varying depending on the state and with new models of practice⁴⁷47 Adams AJ. Pharmacist prescriptive authority: lessons from Idaho. Pharmacy (Basel) 2020; 8(3):112.. This advance is accompanied by the desire of the professional category, who show interest in exercising this activity⁴⁸48 Vu K, Rafie S, Grindlay K, Gutierrez H, Grossman D. Pharmacist intentions to prescribe hormonal contraception following new legislative authority in California. J Pharm Pract 2019; 32(1):54-61.. Adams et al.¹³13 Adams AJ, Weaver KK. The continuum of pharmacist prescriptive authority. Ann Pharmacother 2016; 50(9):778-784. believes that, as the public and their health service providers become more accustomed to the idea of pharmacist prescribing, independent prescribing models (uncommon in the USA) will become more widely used for a broad range of medicines.

The conditional support of doctors to this modality of pharmacist prescribing has been prone to conflicts of narratives, which can be seen in one study³⁵35 Pojskic N, Mackeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists. Res Social Adm Pharm 2014; 10(2):341-354. that points out a confrontation in the views of the Ontario Pharmacists Association and the Ontario Medical Association. While the representatives and the documents of the medical association were against pharmacist prescribing, arguing that they would place the safety of the patient at risk, documents from the pharmacist organizations argue much to the contrary. This type of conflict was also pointed out in studies in other countries that seek the expansion of the pharmacist’s prescriptive authority²2 Hoti K, Hughes J, Sunderland B. An expanded prescribing role for pharmacists - an Australian perspective. Australas Med J 2011; 4(4):236-242..

One limitation of the present study is related to the choice of the English, Portuguese, and Spanish languages, given that, although they provide a broad search, they may not have contemplated material published in other languages in the databases. Another limitation is the non-extension of the texts beyond those found in the search platforms; however, this was necessary due to the objective of this study. Finally, it is important to consider that, despite the effort to consider high-end databases in the area of health research, the methodological strategy adopted does not presuppose an exhaustive review of all of the articles produced on the subject.

Final considerations

Given the scientific literature found through this literature review, it can be concluded that there is a variety of perceptions among the interested parties regarding pharmacist prescribing. The public in general tends to show little knowledge about the practice, with varied support. The activity of pharmacist prescribing was regulated more than ten years ago in the UK and Canada, but it is still mostly unknown for the majority of the population. In this sense, it is understood that more time is needed for a new practice to become more widely accepted by the population.

Studies show that pharmacist prescribing is generally accepted in practice, but it is not widespread. To a great extent, this can be attributed to logistic and organizational barriers. Although the pharmacists are being trained as prescribers, the necessary structural and organizational changes to support this change did not take place in a collaborative manner. To increase the diffusion of this practical innovation, a radical reorganization of the traditional structures can be considered.

The results of this study show that advances in the area of pharmacist prescribing are recent and have already become significant; however, the professional category of pharmacists still faces major and innumerous challenges to consolidate the practice in the field of health care. Studies geared toward a better understanding of the hindrances of acceptance and adherence to the practice of pharmacist prescribing are essential in order to guide educational actions that seek to overcome these difficulties. As it represents an innovation in health care, a natural resistance to change is expected, especially in such a traditional field as health care. The advantage that the pharmacists have in this field is the confidence of the population in providing clinical activities that involve the follow-up of the professional.

CoAlthough the results do not show studies conducted in Brazil, the knowledge of the international experience is extremely valid in order to anticipate possible scenarios in the country. It is also important to highlight that further study is necessary to open the door to a more in-depth knowledge of pharmacist prescribing practices in the countries that have adopted this system.

References

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