Available online at www.sciencedirect.com

Research in Social and

Administrative Pharmacy 8 (2012) 179–192

Original Research

Collaborative prescribing: A qualitative explorationof a role for pharmacists in mental health

Amanda Wheeler, Ph.D., PGDipPsychPharm, B.Pharm., B.Sc.,C.M.H.P., Reg.Pharm.NZ.a,b,*, Keith Crump, M.Pharm.Pract.,

P.G.DipPubHealth., P.G.DipClinPharm., DipPharm.,DipStratLeadership., Reg.Pharm.NZ.c,d, Monica Lee, B.Pharm.d,

Leigh Li, B.Pharm.d, Ashna Patel, B.Pharm.d, Rachel Yang, B.Pharm.d,Jenny Zhao, B.Pharm.d, Maree Jensen, P.G.DipClinPharm., F.P.S.,

Reg.Pharm.NZ.daSchool of Human Services, Griffith Health, Griffith University, Australia

bSchools of Pharmacy & Nursing Faculty of Medical and Health Sciences, University of Auckland, New ZealandcProcare, New Zealand

dSchool of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, New Zealand

Abstract

Background: Collaborative prescribing has been proposed as an extension of practice for advancedpharmacist practitioners. A lack of research investigating how pharmacists might be most effective as

prescribers in mental health was identified.Objective: To explore health professionals’ and consumers’ attitudes and beliefs that relate to the role ofspecialist mental health pharmacists working as collaborative prescribers within their advanced scope of

practice in secondary care.Methods: Semistructured interviews were conducted with key informants in the New Zealand mentalhealth sector. Participants were selected via a purposive sampling method, including health professionals(n¼ 9) and consumers (n¼ 3). NVivo software was used to analyze data, using a thematic analysis ap-

proach to develop a series of key themes from the interviews. Common themes were extracted, whichwere used to gather results and draw conclusions.Results: The key findings include a widespread acknowledgment of the role of specialist pharmacists as

collaborative prescribers in mental health and as integral members of the multidisciplinary team; however,consumers were unaware of pharmacists’ role in secondary care. The role was seen to extend current prac-tice particularly in medication management after assessment and diagnosis by a medical practitioner. Con-

cerns regarding demonstrating competence, practitioner role/boundary confusion, insufficient training andworkforce development, hesitancy by pharmacists to extend role, consumer awareness, and public percep-tion of the traditional pharmacist role were identified. Solutions discussed included education by the pro-

fession; relationship building, training, and robust competency assessments; and a structured frameworkfor implementing a collaborative prescribing model.

* Corresponding author. Griffith University, Logan Campus, Meadowbrook, Queensland, Australia. Tel.: þ61 7 338

21068; fax: þ61 7 33821210.

E-mail address: a.wheeler@grifith.edu.au (A. Wheeler).

1551-7411/$ - see front matter � 2012 Elsevier Inc. All rights reserved.

doi:10.1016/j.sapharm.2011.04.003

180 Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

Conclusions: This study suggests there was recognition and acceptance of the role that specialist pharmacistpractitioners could play in contributing to the care of mental health consumers as collaborative prescribers;their medication expertise being regarded highly. Further research is necessary to investigate how current

resource constraints will allow for collaborative prescribing to be implemented within the context of mentalhealth practice.� 2012 Elsevier Inc. All rights reserved.

Keywords: Nonmedical prescribing; Collaborative prescribing; Mental health; Pharmacy services

Introduction

The pharmacy profession in New Zealand andworldwide is currently undergoing considerablechange.1-7 Historically, the pharmacist’s role en-

tailed the preparation and dispensing of medicinesbut has evolved over the last 2 decades towarda more patient-orientated practice.8 New technol-

ogy and technician roles and services have beendeveloped to reduce the time spent by pharmacistsin dispensing functions and facilitated their pro-

gression toward medicine management servicesandpatient-focused roles.7,9 This shift has occurredalongside a global focus on evidence-based prac-tice, increased complexity of drug therapy and the

concept of clinical pharmacy.7,9,10

A National Framework for Pharmacist Ser-vices,11 and the Pharmacy Council of New Zealand

(PCNZ),12 outlined 5 new pharmacist services (andthe corresponding competencies for these medicinemanagement services) to be offered to benefit the

public: health education, medicines and clinicalinformation support, medicines use review andadherence support, medicines therapy assessment,

and comprehensive medicines management.The PCNZ first proposed designated prescrib-

ing authority for pharmacists in 2007, as part of thecomprehensive medicine management level of ser-

vices. Although stakeholder feedback to the regu-latory framework for advanced practitioners waspositive, collaborative practice was identified as the

preferred model; that is, pharmacists participatingas prescribers within a multidisciplinary healthcare team.13 At a stakeholdermeeting inNovember

2009, the Pharmacist Prescriber scope of practicewas proposed whereby “suitably qualified and expe-rienced pharmacists in advanced clinical practice will

work in close collaboration with other health careprofessionals to provide medicines related healthcare services which result in tangible health benefits

a The term “independent” does not refer to prescribing in

authority available in NZ.7

for patients.”14 The health care services to be pro-vided in this collaborative practice include initia-tion, modification, and monitoring of patients’medications; ordering, performing, and interpret-

ing laboratory and related tests; assessing patients’response to medicine therapy; counseling andeducating patients on their medicine therapy; and

administering medicine therapy.14 The PCNZ hassubmitted an application for a legislation changeto Health Workforce New Zealand, Ministry of

Health in October 2010 allowing for pharmacist-designated prescribing authority (independent pre-scribing authority).a This legislation change wouldenable pharmacists registered in the Pharmacist

Prescriber scope of practice to hold designated pre-scriber status under the Medicines Act 1981.15

Collaborative prescribing practices are expected

to be developed across each of the major therapeu-tic/disease areas, one of which is mental health.Mental health pharmacists are equipped with

specialist knowledge of medicines management tooptimize treatment and therefore, they have thepotential to make significant contributions to the

medicine-related needs of people experiencing a se-rious mental illness.

Mental illness is common, affecting 1 person in4 at some stage in their lifetime.16 In 2004, 7 men-

tal disorders were ranked in the top 20 estimatesof the leading causes of disability including de-pression, bipolar disorder, schizophrenia, alcohol

and drug misuse, dementias, and panic disorder.17

To be effective, treatment in mental health shouldincorporate pharmacological, psychosocial, and

psychological interventions. Psychotropic medi-cines are an important intervention used acutelyand for long-term maintenance for a number of

serious mental disorders. Like all interventions,pharmacological treatment needs to be tailoredindividually for optimal management because

isolation; rather, it is the legal description of prescribing

181Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

these medicines typically have complex profilesand are associated with significant side effect bur-den.18 However, these medicines often are foundto be used suboptimally,19-27 and consumer adher-

ence over the long term can be problematic.28-30

Most mental health pharmacists work withininpatient and community secondary care psychi-

atric settings as pharmacotherapy experts, obtain-ing medication histories, providing consumer andpractitioner education, monitoring and consulting

on individual medication regimens, and liaisingbetween prescribers and dispensers in primary andsecondary care settings. There are a number of

small studies and evaluations investigating theoutcome of pharmacist’s involvement in mentalhealth care and overall these support pharmacistinvolvement.31-34 A systematic review of the studies

(1972-2003) reported that most examined the roleof clinical pharmacists as consultants or educatorswith demonstrated improvements in the safe and

effective use of psychotropic medicines.32 How-ever, 5 studies included clinical pharmacists withlimited prescriptive authority; in otherwords, those

able to prescribe or adjust medicines within a de-pendent prescribing model under protocol.32,35

The most recent of these was conducted in the

United States (2003), with pharmacists workingunder supervision from psychiatrist mentors ascare managers for treatment of depressive symp-toms. The study found positive outcomes on anti-

depressant adherence over 6 months and greaterprovider and patient satisfaction compared withthe control group.36

There is limited literature focusing on collab-orative or independent nonmedical prescribing inmental health, and this has predominantly in-

vestigated nurse practitioners having prescriptiveauthority37-41; no studies were found looking atpharmacists in this role. Rana et al38 surveyedpsychiatrists’ views of nurse prescribing in the

United Kingdom and found that although therewas agreement in principle from psychiatrists itwas not clear how this should be implemented.

They recommended that future research shouldbe more in depth to gather richer data from med-ical personnel about how they perceive the emer-

gence of nonmedical prescribing.In light of the lack of information anddiscussion

in the literature about how pharmacists might

contribute effectively as prescribers in mentalhealth, it is timely and appropriate to considerthis. Therefore, the aim of this study was to explorehealth practitioners’ (HP) and consumers’ attitudes

andbeliefs that relate to the role of specialistmental

health pharmacists working as collaborative pre-scribers within their advanced scope of practice insecondary care.

Methods

This study formed a final-year project for 5

Bachelor of Pharmacy students at theUniversity ofAuckland, New Zealand. Ethics approval wasobtained from the University of Auckland Human

Participants Ethics Committee.

Study design

A qualitative approach was chosen as the most

appropriate method for this study.42,43 This re-search was context dependent and took into con-sideration the perspectives and values of the keyinformants.42 The research question was broad

and generalized, and used a semistructured inter-view to approach key informants in a receptivemanner. This is known as a general inductive the-

matic methodology, often used when describinga series of ideas or themes used by observationsrather than assumptions.42,44

Participants were health professionals (psychi-atrists, nurses, and pharmacists) and mentalhealth consumers selected via purposive sampling,

allowing researchers to recruit individuals whowould be relevant to this study and be the mostinformative in answering the proposed question(s)about the potential process and impact of phar-

macists taking on a collaborative prescribing rolein mental health.42 The health professionals allheld New Zealand practicing certificates and their

work places were from both the north and southislands of New Zealand. All participants whowere invited agreed to participate in the research.

Semistructured interviews with open-endedquestions provided the researchers the opportunityto explore participants’ viewpoints in detail, elabo-rating on simple replies and clarifying any ambigu-

ous answers.44 Key informants were given theopportunity to freely discuss their perspectives, per-sonal experiences, and raise any issues or concerns

that were important to them as an individual and/or as a representative of their profession. The inter-view contained a framework of questions with

prompts aimed at ascertaining the participants’current role in mental health, before probing forviews on prescribing and the potential role of phar-

macists as collaborative prescribers. This frame-work of questions was developed after reviewingthe literature and identifying gaps in knowledge

182 Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

(Table 1). On agreement of the interview frame-work, 2 pilot interviews were conducted (in thepresence of a supervisor) to further refine the

proposed interview strategy.42 The interviewframework was amended slightly for use with con-sumers and began by ascertaining the participants’experience of mental health services before pro-

gressing to their views on prescribing and pharma-cists as prescribers in mental health. The definitionof collaborative prescribing used in the study was

“a cooperative practice relationship between a phar-macist and a physician. The physician diagnoses andmakes the initial treatment decisions and the pharma-

cist selects, initiates, monitors, and continues or dis-continues medication as appropriate to achieve theagreed patient outcomes. The physician and pharma-cist share the risk and responsibility for the patient

outcome.”35

Participants were engaged in a 30-45-minuteinterview at a location agreed upon by individual

participantsbetween JulyandSeptember 2009.Thisallowed key informants to speak freely and openlyin an environment in which they felt comfortable.42

Each interview was audio recorded and this wasthen transcribed verbatim by the researchers.

There were 12 participants interviewed either

in person (n¼ 9) or via telephone (n¼ 3) and the

Table 1

Interview framework

Health professional Co

Demographics and professional role/experience De

Relationship with pharmacists

� Personal and peer experience

� Qualities

Re

� P

� Q

Pharmacists’ role (current)

� Knowledge, skills, expertise

� Contribution to mental health

� Strengths and weaknesses

Ph

� K

� C

� S

Nonmedical prescribing� Pharmacists as prescribers

Tr� N

Impact of pharmacists as collaborative prescribers

� Access (settings), continuity, monitoring, acceptability

� Consumer outcomes

� Benefits and risks

� Services for M�aoria

Ph

� B

� S

� C

Relationship with pharmacist prescribers (future)

� Professional roles/boundaries

Re

� P

Questions/comments/other views to share Qu

a M�aori, the indigenous people of New Zealand make up 14

prevalence of mental illness,64 and overall significant health di

transcripts were independently reviewed by one ofthe research supervisors (KC). Reflective journal-ing was also used by the students and discussed

with the supervisor. This process was to ensurethat the interviews explored the topic fully andthat interview process was not unduly influencedby the student’s perspective. Data saturation was

established within each of the informant popula-tions (mental health professionals and mentalhealth consumers) when the transcripts did not

identify any new or emerging thematic material.

Data analysis

Transcripts from each interview were reviewedand analyzed via a thematic analysis approach,42

using NVivo 8� software (QSR International

Pty Ltd). This analysis was performed to identifycommon underlying ideas and opinions, whichsurfaced from participants’ responses. These

were condensed into meaningful units placed un-der appropriate themes as tree nodes, whichwere further stratified to subcategories. These sub-

categories subsequently were collated as 4 maincategories. Each category defined a particulartheme, which was used to gather results anddraw conclusions.44 The analysis was undertaken

by the students in pairs and was then discussed

nsumer

mographics and service use experience

lationship with pharmacists

ersonal experience

ualities

armacists’ role (current)

nowledge, skills, expertise

ontribution to mental health (part of health care team)

trengths and weaknesses

aditional prescribing rolesonmedical prescribing

armacists as collaborative prescribers

enefits and outcomes

afety

oncerns (privacy etc)

lationship with pharmacist prescribers (future)

ersonal expectations

estions/comments/other views to share

.0% of the population,63 and are known to have a higher

sparities compared with non-M�aori.65

183Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

with one of the supervisors (KC). Possible alterna-tive thematic groupings were explored and adop-ted or discarded, based on reflection and thestudents’ journaling as a means of strengthening

the credibility of the findings.45

Results

Study participants

Twelve key informants participated in the study(9 were female) consisting of 9 health professionals(including psychiatrists, specialist pharmacists, and

nurse practitioners) and 3 mental health con-sumers. The HP participants all were working inclinical practice across a variety of secondary caresettings, including community, culture specific,

addictions and general psychiatry. In addition,some participants held roles in clinical leadership,professional bodies, and academic settings. The

consumers (C) interviewed differed in age, gender,and ethnic backgrounds.

Themes

The data collected from the participants weregrouped around 4 key themes, which are described

Fig. 1. Key overar

in Fig. 1. The major themes that were developed bythe researchers based on the participants’ viewsrelating to the central question of pharmacists par-ticipating in collaborative prescribing included the

participants beliefs and perceptions about the cur-rent role of pharmacists, issues relating to collabo-rative prescribing, the complex nature of themental

health environment, and consumer-specific experi-ences and concerns.

Pharmacists’ role

The key issues addressed in the semistructuredinterviews were the beliefs regarding the role ofpharmacists’ working with the mental health team

as collaborative prescribers. All participants identi-fied that pharmacistswere recognized as having spe-cialist knowledge regarding medicines with a betterunderstanding and knowledge than other health

professionals, as illustrated by the following quotes:

“Pharmacists have the in depth knowledge

around medication and how medication works

and what are the adverse possibilities associated

with medication and they have more of that

background and understanding and knowledge

in that specific area.” [Participant 9 HP]

ching themes.

184 Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

“I always thought of the pharmacist as the person

that would be able to give me the best information

about themedicationsweare using, as opposed to I

guess, a doctor.” [Participant 5 HP]

A number of participants emphasized thatpharmacists, especially those working within men-tal health teams provided an evidenced-based

perspective about medicines:

“They [pharmacists] are good at looking at the

evidence based material so they are good at

assessing literature, good at knowing what the

literature is doing, medical staff are. specialised

in their focus and they are probably not as aware

of some of these things as pharmacists.” [Partic-

ipant 7 HP]

“When I am thinking of changing a person from

one drug to another, to find what the best titration

schedule is and if it’s a really complicated person, if

I know I am not up to date with literature, I will

phone a pharmacist and get advice about that, I

think it is fantastic.” [Participant 6 HP]

The role of the pharmacist within specializedmental health teams was well recognized with

participants commenting that pharmacists wereable to perform medication reviews and assessadverse effects and possible treatment options for

mental health consumers:

“[I contact the pharmacist] if I have any queries.which I do quite frequently, often with people who

come in with long lists of medications or are

concernedabout the side effectsorwonderingabout

starting a new medication and someone who been

on a lot of medications.” [Participant 8 HP]

The positive regard expressed for pharmacistsknowledge and participation was balanced by

some participants expressing concerns aboutpharmacists’ ability to interact with consumers:

“When you’ve had mental problems you are very

sensitive to people’s body language, looks, you

know the way they look, the way they talk. At

the moment my pharmacist is a slightly paternal

figure who is just a little bit disapproving espe-

cially [regarding] clonazepam that I am pre-

scribed.” [Participant 10 C]

“The pharmacist has to decide, as a professional

they need to have more focus on actual patient

interactions not just giving advice about medica-

tion but seeing that whole aspect of a patient’s

care.” [Participant 2 HP]

Collaborative prescribingParticipants expressed that trained pharma-

cists who gained the advanced scope of practice

could prescribe medicines in a collaborative modelwithin the multidisciplinary teams despite theirnonmedical background. Thereby suggesting a

mandate for this as a legitimate role:

“If they get through it [training/education] and

get credentials and are competent to do the role

then I don’t think there is any reason they

shouldn’t.” [Participant 4 HP]

“As long as someone is working within their

scope of practice it doesn’t matter whether they

are medical or not as long as they are working

at the level of their ability and expertise then it

is appropriate.” [Participant 1 HP]

Many practitioners thought that mental healthpharmacists were already involved in prescribingdecision making and writing medication orders

for medical authorization, and that workingwithin a collaborative prescribing model theyshould feel comfortable undertaking such a re-

sponsibility; as they had the knowledge and abilityto do so. Participants indicated that shifting thefocus of a pharmacist’s activities away from rec-ommending, toward prescribing, seemed to be

a natural progression of their role and that legis-lating collaborative prescribing would simply bean extension of current expectations:

“The pharmacist being able to prescribe to follow

a plan, continue a plan, possibly even when the

doctors are not able to be there, with monitoring,

I feel that’s probably something we do at the mo-

ment anyway.” [Participant 3 HP]

“[Clinical pharmacists] are helping to select and

make decisions around treatment with physicians,

starting monitoring, making decisions when to

discontinue and so on. They are absolutely capa-

ble of doing those things.” [Participant 7 HP]

Despite the positive endorsement, there were

concerns raised by participants regarding howsuch a prescribing scope of practice would actu-ally function within the current health care

environment stating that employment and inter-professional issues would need to be considered:

“You know there is a whole lot of complexity

around conditions of employment and remuner-

ation and all of those sort of things that have to

be worked through to enable these.what sounds

like nice ideas and which I probably believe is

a nice idea but turning that into a reality is not

necessarily all that easy.” [Participant 9 HP]

A new scope of practice for pharmacists ascollaborative prescribers was discussed against

a background of established roles and hierarchies

185Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

with participants acknowledging that change willrequire education and evaluation:

“I think there would need to be a fair bit of work

to be done to educate people around what it is

[pharmacists] do and what training you’ve done,

because there will be a complete assumption

that there’s a hierarchy, and the psychiatrist.they train for 6 years., I think in people’s minds

there will be a hierarchy and people will make as-

sumptions and people will need support to under-

stand why this is different.” [Participant 11 C]

“That is good intent, but the reality is that you are

potentially treading on people’s toes and tradi-

tional positionswithin ahealthcarehierarchy.the

whole notion of a professional moving into a new

area will seem like a threat.” [Participant 9 HP]

However, the evolution of advanced scopes ofpractice was expressed by 1 participant as a way

of overcoming concerns relating to the traditionalroles and hierarchies:

“I think if you’ve got a doctor that’s working at

an advanced level, you’ve got a pharmacist work-

ing at an advanced level, you’ve got a nurse

working at an advanced level, you’ve got a group

of colleagues as opposed to people getting stuck

on, you know, I’m the doctor, I’m the nurse,

I’m the pharmacist, so I think that the barrier

of being discipline specific isn’t there, when

you’ve got a team working at an advanced level.”

[Participant 5 HP]

There was a strong impression expressed by theparticipants that to establishmental health pharma-

cists in a collaborative prescribing role there wouldneed to be a shift in the way pharmacists practicedwith appropriate training and development:

“A step up for pharmacists. and a step away

from the clinical checking to actually writing

prescriptions and being involved in not just

recommending but actually prescribing medica-

tions so I think that would take a lot of educa-

tion.” [Participant 4 HP]

There also was a perception that pharmacistsmay be apprehensive about taking up this newrole and its associated responsibilities:

“[Pharmacists] are a little bit hesitant to take on

responsibility. we are not used to being the

person at the end of the line except when it comes

to checking medication. actually stepping up

and taking up responsibility and being at the final

end of it.” [Participant 4 HP]

This was reinforced by a number of pharmacistparticipants who expressed that they would need

to up skill themselves and increase their contactwith consumers to take on a collaborative pre-scribing role:

“I don’t think I’ve had sufficient post-graduate

training at themoment, and the job that I’mdoing,

I just don’t have enough patient contact time. I

would need more time. I think I should probably

do more training as well.” [Participant 3 HP]

Trust and support from leaders within themultidisciplinary team and the pharmacy profes-sion were also identified bymany key informants as

being central to the success of a collaborativeprescribing model for pharmacists:

“We need clinical leaders. who believe that

pharmacists should be [collaborative prescribers].

With that endorsement it’s much easier for phar-

macists to move into this role.with the right

support.” [Participant 2 HP]

“Just like nurse prescribing where initially people

were a little anxious but if they felt it was

something thedoctors believed in and supported.then I thinkpeoplewill be finewith it.” [Participant

2 HP]

There were concerns expressed by participants

regarding the complexity of prescribing and po-tential risks and harms to consumers if errorsoccurred with a key focus on the need for high-

quality consumer care:

“So I think as professionals,. we need to set the

standards, so that there isn’t any undermining of

the quality of patient care, except that I know

what the error rate is like with medications, it’s

a complete nightmare.” [Participant 6 HP]

There was also acknowledgment that a collabo-

rative model was about mitigating risk by sharingresponsibility:

“I guess it’s when you talk about collaborative

prescribing here as the risk being shared.” [Partic-

ipant 1 HP]

Overall, participants considered that pharma-cists with the appropriate skills, training and

relationships with mental health consumers couldhave a positive impact on care and outcomes.

Mental health care environmentThe environment in which mental health care

is provided was identified as an important factorby all study participants. The team nature andmultidisciplinary make up of mental health ser-

vices was described by participants with a strongemphasis on shared decision making:

186 Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

“We work as part of the multidisciplinary team

with nurses, social workers, occupational thera-

pists, psychotherapists, psychologists and the

doctors, and then we do have a pharmacist who

comes as well but unfortunately just once aweek.that is how we work anywaydas a team. We talk

to, we bounce opinions off each other, and we get

extra advice and themore information we have the

better so I think it has been really useful.”

[Participant 8 HP]

HP participants commented that pharmacists’added value to the clinical decision making espe-

cially in the mental health care environment whereteam members used each other’s skills to optimizeconsumer outcomes:

“A doctor’s knowledge alone in my view is insuf-

ficient when you are dealing with complex people

with complex illnesses. I would love it if there

was a pharmacist on the team. so if I had

[a pharmacist] on the team it would be far better

for people we look after, it would make me feel

like I was practicing a much better standard of

medicine.” [Participant 6 HP]

“Taking a closer look at medications and ration-

alising them; and I know we’ve definitely had

some issues with people who have had maybe

a personality disorder plus a whole lot of mood

and anxiety symptoms and maybe substance

abuse who have had medications added and by

the time they get to us they’ve got this long list

of medications. it would be nice to have a phar-

macist working alongside us to try to rationalise

and reduce those in a very step-wise slow fash-

ion.” [Participant 8 HP]

Many health professionals reported that con-tinuity of care in mental health services could be

improved and that pharmacists were viewed as anessential component of continuity:

“[The pharmacist] has more continuity and

almost knows what’s going on more than anyone

while you get doctors changing quite often.”

[Participant 3 HP]

Participants also commented that the mentalhealth environment was impacted upon by work-

force constraints where shortage of psychiatristsand also clinical pharmacists may have negativeimpacts on consumer care:

“I’m horribly aware doctors are a rate-limiting

step, we keep everybody waiting. It’s not good

for the patients; it’s not good for teams.” [Partic-

ipant 6 HP]

“I mean here we’ve got one consultant at the mo-

ment, being able to decrease his workload and in

the other small communities where there they’ve

only got a consultant visiting once a week or

once a fortnight whatever it is. I definitely think

access will increase then the patient will be able to

be seen more frequently. But there could be ten

psychiatrists and there may only be one clinical

pharmacist in that respect.” [Participant 4 HP]

However, participants acknowledged that clin-ical pharmacists working at an advanced level ofpractice were also a limited resource so that

collaborative prescribing may have minimal im-pact on the issue of improving access for con-sumers to HPs:

“. the only weakness I suppose is that pharma-

cists are a small resource sometimes in big

organisations, so they are stretched. [Pharma-

cists] are not necessarily seen at every MDT

[multidisciplinary team] meeting because of the

extent of which they are stretched and their

expertise is stretched.” [Participant 9 HP]

Consumer issues

The participants expressed a number of specificissues relating to the experience of mental healthconsumers that need to be considered in the

context of pharmacist prescribing when develop-ing a prescribing and treatment plan. These issuesincluded the complex pervasive nature of mentalhealth disorders, the influence of cultural factors,

especially M�aori-specific cultural issues, and theimpact of stigma regarding mental illness.

Participants considered that stigma can result

in adverse effects for consumers and create a bar-rier for providing best care:

“I think that by the tablets that are prescribed,

the pharmacist must know or have an idea of

what they’re prescribed for and there is a sense

that I feel of slight self-consciousness and slight

embarrassment because the pharmacist knows

and when we don’t speak about it, or she

wouldn’t know exactly but has a rough idea

that I have a mental health problem.” [Partici-

pant 10 C]

Cultural issues relating to M�aori concerns wereexpressed in terms of the potential for a lack ofengagement between pharmacists and M�aori con-sumers. This view was expressed in the global

context of Western medicine being too narrow inits approach and the challenge for all healthprofessionals to improve engagement with M�aoriconsumers and their families:

“They [M�aori] have a broader view [of health], so

it’s about how they view health but it is also

about how health services go about trying to

187Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

sort of interact with them. I mean pharmacists

are by definition seen as highly specialised experts

in medicine.and that’s some part of what M�aori

find a bit alien in how we deliver our services”

[Participant 7 HP]

Participants identified that the development of

a treatment partnership with the consumer thatused a collaborative model with health profes-sionals would improve care and this was man-

dated by a consumer participant:

“I think if medication works for people, then

that’s fantastic. But I think the whole process of

diagnosing people and putting them on medica-

tion and being diagnosed, how cool would it be

if that process actually built something if it was

a partnership.” [Participant 11 C]

“It’s mysteriousdthe medicines I take. I think I

take too many medicines but [doctors] are hesi-

tant, I’d like to talk to pharmacists about that

. doctors just say ‘take this and you’ll get bet-

ter,’ I want a pharmacist to tell me more about

my medicines.” [Participant 12 C]

Consumers thought that pharmacists involvedin a collaborative prescribing role would comple-

ment the multidisciplinary team. They currentlyviewed medical practitioners as the main decisionmaker involved in their care because they had

limited experience with nonmedical prescribersand minimal contact with pharmacists in thesecondary care setting. They reflected their expe-

rience of pharmacists largely from their ongoingrelationships with community pharmacists whenthey collected their medication. However, theywere aware of the evolving nature of the health

sector and believed that pharmacists could con-tribute by providing expertise and knowledge topatient-orientated care:

“I’d feel very comfortable [with pharmacist pre-

scribers], because it would be another link for me

in the total circle of people looking out for me

andmanaging it [mycondition].” [Participant 10C]

Discussion

Overall, participants in this qualitative studyrecognized that pharmacists working in mentalhealth are specialists in the area of medicine

management, and that their skills enhance thedelivery of health care to mental health con-sumers. This reinforced the essential role that

clinical pharmacists currently have as mentalhealth team members that has been reportedelsewhere.31-33 Pharmacists’ skills in aiding high-

quality evidence-based prescribing were also em-phasized by participants, in particular contribut-ing to multidisciplinary treatment planning andcontinuity of care. Collaborative prescribing was

acknowledged as a legitimate role for appropri-ately trained pharmacists in mental health.

Collaborative prescribing is the use of a health

care team to determine the pharmacotherapeuticneeds of a mental health consumer. The partici-pants expressed the appropriateness of a partner-

ship of health professionals including pharmacistsas a good way of providing treatment for mentalhealth consumers and were supportive of the

expert contribution of a pharmacist to the mentalhealth care team, provided issues around trainingand competency assessment were addressed in theauthorization of the pharmacist as prescriber.

Proposed training programs for pharmacist pre-scribers in New Zealand will be required toinclude a practicum component (300 hours) where

undertaking a consumer prescribing consultationwill be learned in a supportive collegial mannerunder the supervision of a designated medical

practitioner.15 This may help to address concernsexpressed by some participants around the abilityof a pharmacist to carry out the process of consul-

tation, rather than the mechanics of “writing”a prescription.

The act of prescribing is a “communication” ofa decision to treat between the consumer and all

other people involved in delivering health care tothat person.46 If the decision to treat with medica-tion is made then the pharmacist or nurse and the

psychiatrist could be responsible for the role ofprescriber, if each of these advanced practitionershad the knowledge and skills to undertake this

role. The proposed collaborative pharmacist pre-scriber scope of practice would therefore be legiti-mizing what participants described was currentlyhappening in a de facto manner in some specialized

mental health services; a medical prescriber autho-rizing the “pharmacotherapy recommendations orplan” developed by a specialist pharmacist with

whom they have a good working relationship.A national survey of hospital pharmacists inAustralia also found that pharmacists were under-

taking a high level and range of de facto prescrib-ing activities (such as discharge prescribing), whichappeared to be accepted clinical practice and that

the next step in validation of this role would beto enable legislative change to develop collabora-tive models of prescribing.47

This New Zealand study found that mental

health consumers often failed to recognize

188 Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

pharmacists as members of the health care teamproviding services for them. Their experience ofpharmacists was reported to be largely that of the

community pharmacist.Respondents reported thatsometimes pharmacists appeared to have a negativeattitude to mental health consumers and their useof medicines. The stigma around mental health,

although acknowledged by the service providers isreal and continues despite the best efforts of heathfunders to address this with public media cam-

paigns such as Like Minds Like Mine (www.likeminds.org.nz) that use high-profile personalities(eg, John Kerwin, former New Zealand All Black

[rugby player] 1984-1994) to describe their mentalhealth experience. However, consumer study par-ticipants welcomed the opportunity to have a phar-macist as part of their health care team and

recognized their expertise inmedicinemanagement.A review of the literature relating to phar-

macists’ communications skills by Shah and

Chewning48 revealed that most research has fo-cused on the ability of the pharmacist to imparta message to health consumers and has identified

a gap in developing an understanding of the in-teractive component between pharmacists andhealth consumers. Research exploring adherence

to medicines in mental health has identified a num-ber of factors that influence ongoing medicine ac-ceptance that include adverse effects, medicinecomplexity, and the quality of the treatment alli-

ance between the consumer and the health careteam.49,50 The importance of engagement byhealth care practitioners with consumers has also

been well established,51 especially in relation tosupporting consumer health literacy.52 The abilityof pharmacists to impart medicine information

was evaluated by video taping 10 pharmacists us-ing staged scenarios; pharmacists were observedusing vague terminology and focusing on adverseevents and safety issues rather then potential

health benefits of medicines.53 Attempts to im-prove pharmacist communication skills when pro-viding counseling for health consumers have been

developed using simulated patient methodology.54

These models need to be seriously considered byeducation providers to improve pharmacist con-

sumer communication when programs and quali-fications for pharmacist prescribing are beingdeveloped.

Meeting the cultural needs of mental healthconsumers when providing care is also importantin the development of an effective health carerelationship.55 This has been recognized by the

New Zealand Pharmacy Council and cultural

competency will be a requirement for all NewZealand-registered pharmacists (in the generalpharmacists scope of practice) from 2012 with

a change in the Competency Standards.56

For pharmacist prescribers to be successfulin delivering improved health care for peoplerequiring mental health services, there must not

only be training for pharmacists, but also accep-tance from the pharmacy profession and otherclinicians especially at a leadership level and from

the public. Building on successful campaigns al-ready in place to reduce stigma around mentalhealth could be ameans to attain this.Additionally,

pharmacists need to increase their visibility espe-cially when providing pharmaceutical care forconsumers; as Charles Hepler suggested “.weshould let patients see us caring for them, whenever

we are doing that.”10

Forms of dependent pharmacist prescribinghave been established widely in North America,

in some states of Canada this has evolved furtherto include independent prescribing in a collabora-tive relationship and the United Kingdom has

established supplemental (a form of dependentprescribing) and independent prescribing.7 Anevaluation in the north east of England where

pharmacist prescribing has been possible for thelast 7 years (supplementary prescribing since late2003 and independent prescribing since early2006), found most of the pharmacists who had un-

dertaken prescriber training (62%) were reportedas working in secondary care and around 10%of hospital pharmacists were prescribers.57 Baqir

et al58 reported that although the number of phar-macist prescribers overall was low and the volumeof prescriptions similarly low, this was even worse

in the primary care setting (about 1% of all itemsprescribed in this setting). Although pharmacistsin all areas of practice cited organizational bar-riers as the primary issue for the low uptake, it

was found to be worse in the primary care settingwhere there were no defined pharmacist prescrib-ing roles. In both settings (including hospitals),

the study found that individual pharmacists thatprescribe had identified a specific need and devel-oped services and clinics in response to this rather

than from a strategic implementation plan led atan organizational level.57 In secondary care, thesepharmacist prescribers described their close work-

ing relationships with medical staff as invaluablebecause their prescribing roles had evolved inthis opportunistic manner.58 Furthermore, an un-published national evaluation of independent

nurse and pharmacist prescribing in the United

189Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

Kingdom (2008-2009) by Southampton and KeeleUniversities reported very low uptake by eitherprofessional group in mental health settings.59

Prescribing in any form is not yet part of the

scope of practice for New Zealand pharmacists.As such, the opinions and beliefs expressed bythe participants about collaborative prescribing

are important in establishing support for thePCNZ application, which is currently beingreviewed for approval by Health Workforce

New Zealand (which manages the process forthe Ministry of Health). However, if NewZealand is to learn from the United Kingdom

experience, then clear strategies at an organiza-tional level (such as district health boards andprimary health care organizations) are needed todevelop prescribing roles; supported by associ-

ated policies and procedures. This will be impor-tant to ensure sustainability of the new roles andto avoid reliance on motivated and innovative

individuals in localized services. Conductingdemonstration pilots in a range of practicesettings could be a means of assisting this

development and implementation process. Fur-thermore, robust and rigorous evaluations ofthese new intervention models need to be con-

ducted to identify the most cost-effective role forpharmacist prescribers to improve health out-comes for mental health consumers.60 A numberof as yet unpublished pharmacist prescribing

pilot evaluations in nonmental health settings inAustralia (hospital preadmission clinics and com-munity specialist clinics9) have used a uniform

framework to ensure prescribing quality andsafety which will provide information vital tosuccessful implementation.

Nonmedical prescribing has been proposed asa solution for medical staffing shortages, espe-cially getting discharge, leave, and repeat pre-scriptions written but as reported by the New

Zealand study participants there are also work-force shortages in pharmacy, especially in second-ary care mental health services. The current pool

of existing pharmacists with specialist knowledgein mental health may prove to be another barrierto successful implementation. This problem is not

specific to the New Zealand practice setting andwas similarly identified by the United KingdomPsychiatric Pharmacy Group and the College of

Mental Health Pharmacists when supplementarypharmacist prescribing was legislated.61 Develop-ing appropriately trained specialist pharmacistsin mental health needs to be addressed to sustain-

ably bridge some of these workforce gaps.

Limitations

As with any qualitative research, there isa limited ability to generalize the results of thestudy to most of the health professionals working

in mental health service delivery in New Zealandor to a wider clinical pharmacy setting such asother specialty areas of practice or to a primarycare setting.62 Some interviews were conducted by

telephone, which may have resulted in reduced in-teraction and lack of verbal clues that could haveimpacted on the expression of material. The

health professionals who participated in the studywere purposively sampled and were specialistsworking in secondary care often holding leader-

ship roles within their profession or area of prac-tice and were all practicing clinicians; the mentalhealth consumers were all currently engagedwith or recently engaged with a mental health pro-

fessional at a secondary care level; and thereforethe results provide good insight into their beliefsand experiences. The views expressed by health

professionals were consistent, and purposive sam-pling was designed to illicit responses from peoplewith an interest or knowledge in this area. This is

not necessarily a weakness of the study as long asattempts to generalize the findings are not made.Similarly, the consumers were selected through

convenience sampling, and although familiarwith representing the views of mental health con-sumers engaged with secondary care public mentalhealth from their experiences, these may not have

reflected the range of services delivered in NewZealand. A larger sample of consumers may haveprovided the study with a broader perspective of

issues related to pharmacist prescribing.Although data saturation was reached in this

exploratory study, it is possible that a complete

description of beliefs and opinions about phar-macists as collaborative prescribers in mentalhealth was not achieved. It was beyond the scopeof this study to examine this; however, the largely

positive response of participants to involvingpharmacists in collaborative prescribing for men-tal health consumers could be addressed in future

study such as a national survey of secondary caremental health providers.

Conclusion

This study suggests there was recognition

and acceptance of the role of specialist mentalhealth pharmacist practitioners as collaborativeprescribers; their medication expertise being

190 Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

regarded highly. Further research is necessary toinvestigate how current resource constraints willallow for collaborative prescribing to be imple-

mented in practice, and pilots or demonstrationsites are needed with robust evaluation to investi-gate how this resource is best used at an organiza-tional level to improve consumer access and

outcomes.

Acknowledgments

The research team would like to express theirgratitude to all the participants who shared their

views and experiences. They also appreciate theassistance provided by Sandy Bhawan andBronwyn Clark from the PCNZ, for sharing thesubmission of the proposed pharmacist prescriber

scope of practice and Shane Scahill for his feed-back on early drafts of the paper. They alsoacknowledge the School of Pharmacy at the

University of Auckland for supporting the project.

References

1. New Zealand Ministry of Health. Medicines New

Zealand 2007. Available at: http://www.moh.govt.

nz/moh.nsf/indexmh/medicines-nz. Accessed 19.01.

09: ISBN 978-0-478-31255-3.

2. Pharmaceutical Society of New Zealand. Focus on

the future: ten year vision for pharmacists in New

Zealand: 2004-2014; 2004. Available at: http://psnz.

org.nz/public/home/documents/10_yea_plan.pdf.

Accessed 21.12.10.

3. United Kingdom Department of Health. Pharmacy

in England: building on strengths-delivering the

future; 2008. Available at: http://www.dh.gov.uk/

en/Publicationsandstatistics/Publications/Publications

PolicyAndGuidance/DH_083815. Accessed 19.01.09:

ISBN 9780101734127.

4. United States Department of Health and Human

Services. Pharmacy affairs and 340B drug pricing

program; 2008. Available at: http://www.hrsa.gov/

opa/introduction.htm. Accessed 19.01.09.

5. Gilbert L. Pharmacy’s attempts to extend its roles:

case study in South Africa. Soc Sci Med 1998;47:

153–164. doi:10.1016/S0277-9536(98)00022-7.

6. Wheeler A, Hale A, Jensen M, Coombes I, Stokes J,

Stowasser D, Nissen L. Pharmacist prescribingd

taking steps toward the future. J Prim Health Care

2010;2:72–73.

7. Abramowitz PW. The evolution and metamorphosis

of the pharmacy practice model. Am J Health Syst

Pharm 2009;66:1437–1446. doi:10.2146/ajhp090286.

8. Bissell P, Traulsen JM. Sociology and Pharmacy

Practice. 1st ed. London, UK: Pharmaceutical Press;

2005.

9. Nissen L. Prescribing rights for pharmacists in

Australiadare we getting any closer? Pharmacist

2008;27:624–629.

10. Hepler CD. A dream deferred. Am J Health Syst

Pharm 2010;67:1319–1325.

11. District Health BoardsNewZealand. DHBNZPhar-

macy Advisory Group. New Zealand National Phar-

macist Services Framework: Version 1; 2007.

Available at: http://www.dhbnz.org.nz/Site/SIG/

NPSF/NPSF-Framework.aspx. Accessed 21.12.09.

12. Pharmacy Council of New Zealand. Medicines

management. Definition, levels, competence frame-

work [PDF]; 2006. Available at: http://www.pharma

cycouncil.org.nz/cms_show_download.php?id¼44.

Accessed 21.12.09.

13. Pharmacy Council of New Zealand. Feedback on the

consultation on the proposed advanced scope of

practice and qualifications for pharmacists; 2007.

Available at: http://www.pharmacycouncil.org.nz/

cms_show_download.php?id¼15. Accessed 22.09.09.

14. Pharmacy Council of New Zealand. Collaborative

Pharmacy PracticedPharmacist Prescribers: Report

of Key Stakeholders Meeting 6 November 2009;

2009. Available at: http://www.pharmacycouncil.

org.nz/cms_show_download.php?id¼128. Accessed

08.04.10.

15. Pharmacy Council of New Zealand. Pharmacist Pre-

scriber Scope of PracticedConsultation Outcome

Report; 2010. Available at: http://www.pharmacy

council.org.nz/whats_new. Accessed 23.12.10.

16. World Health Organisation (WHO). The World

HealthReport 2001:MentalHealth:NewUnderstand-

ing, New Hope. Geneva, Switzerland: WHO; 2001.

17. World Health Organization. The global burden of

disease: 2004 update; 2008. Available at: http://

www.who.int/healthinfo/global_burden_disease/GBD_

report_2004update_full.pdf. Accessed 09.03.10: ISBN

978 92 4 156371 0.

18. Stahl SM. Stahl’s Essential Psychopharmacology:

Neurioscientific Basis and Practical Applications.

3rd ed. New York: Cambridge University Press;

2008.

19. KeksNA,AltsonK,Hope J, et al. Use of antipsycho-

sis and adjunctive medications by an inner urban

community psychiatric service.Aust NZ JPsychiatry

1999;33:896–901.

20. Owen RR, Feng W, Thrush CR, Hudson TJ,

Austen MA. Variations in prescribing practices for

novel antipsychotic medications among Veterans

Affairs hospitals. Psychiatr Serv 2001;52:1523–1525.

21. Owen RR, Thrush CR, Kirchner JE, Fischer EP,

Booth BM. Performance measurement for schizo-

phrenia: adherence to guidelines for antipsychotic

dose. Int J Qual Health Care 2000;12:475–482.

22. Mort JR, Aparasu RR. Prescribing of psychotropics

in the elderly: why is it so often inappropriate? CNS

Drugs 2002;16:99–109.

23. Leslie DL, Rosenheck RA. Benchmarking the qual-

ity of schizophrenia pharmacotherapy: a comparison

191Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

of theDepartment of VeteransAffairs and the private

sector. J Ment Health Policy Econ 2003;6:113–121.

24. MeagherD,MoranM. Sub-optimal prescribing in an

adult community mental health service: prevalence

and determinants. Psychiatr Bull 2003;27:266–270.

25. Harrington M, Lelliott P, Paton C, Konsolaki M,

Sensky T, Okocha C. Variation between services in

polypharmacy and combined high dose of antipsy-

chotic drugs prescribed for in-patients. Psychiatr

Bull 2002;26:418–420.

26. Paton C, Lelliott P, Harrington M, Okocha C,

Sensky T, Duffett R. Patterns of antipsychotic and

anticholinergic prescribing for hospital inpatients.

J Psychopharmacol 2003;17:223–229.

27. Taylor D, Mir S, Kerwin R. Prescribing in schizo-

phrenia. Evaluating the effect of introducing a new

treatment protocol. Psychiatr Bull 2000;24:106–108.

28. Adams J, Scott J. Predicting medication adherence in

severe mental disorders. Acta Psychiatr Scand 2000;

101:119–124.

29. Cramer JA, Rosenheck R. Compliance with medica-

tion regimens for mental and physical disorders.

Psychiatr Serv 1998;49:196–201.

30. Gray R, Wykes T, Gournay K. From compliance to

concordance: a review of the literature on interven-

tions to enhance compliance with antipsychotic medi-

cation. J PsychiatrMentHealth Nurs 2002;9:277–284.

31. Bell JS, Rosen A, Aslani P, Whitehead P, Chen TF.

Developing the role of pharmacists as members of

community mental health teams: Perspectives of

pharmacists and mental health professionals. Res

Soc Admin Pharm 2007;3:392–409.

32. Finley PR, Crismon ML, Rush AJ. Evaluating the

impact of pharmacists in mental health: a systematic

review. Pharmacotherapy 2003;23:1634–1644.

33. Gable KN, Stunson MJ. Clinical pharmacist inter-

ventions on an assertive community treatment

team. Community Ment Health J 2010;46:351–355.

34. Ellenor GL, Dishman BR. Pharmaceutical care role

model in psychiatry-pharmacist prescribing. Hosp

Pharm 1995;30:371–373.

35. Emmerton L, Marriott J, Bessell T, Nissen L,

Dean L. Pharmacists and prescribing rights: review

of international developments. J Pharm Pharm Sci

2005;8:217–225.

36. Finley PR, Rens HR, Pont JT, et al. Impact of a col-

laborative caremodel on depression in a primary care

setting: a randomized controlled trial.Pharmacother-

apy 2003;23:1175–1185.

37. McCann TV, Clark E. Attitudes of patients towards

mental health nurse prescribing of antipsychotic

agents. Int J Pharm Pract 2008;14:115–121.

38. Rana T, Bradley E, Nolan P. Survey of psychiatrists’

views of nurse prescribing. J Psychiatr Ment Health

Nurs 2009;16:257–262.

39. Harrison A. Mental health service users’ views of

nurse prescribing. Nurse Prescribing 2003;1:78–85.

40. McCann TV, Baker H. Community mental health

nurses and authority to prescribe medications: the

way forward? J Psychiatr Ment Health Nurs 2002;9:

175–182.

41. Wand T, Fisher J. The mental health nurse practi-

tioner in the emergency department: an Australian

experience. Int J Ment Health Nurs 2006;15:201–208.

42. Smith F. Research Methods in Pharmacy Practice.

London: Pharmaceutical Press; 2002.

43. Kairuz T, CrumpK,O’BrienA. An overview of qual-

itative research. Pharm J 2007;277:312–314.

44. Kairuz T, Crump K, O’Brien A. Tools for data

collection and analysis. Pharm J 2007;278:

371–377.

45. Krefting l. Rigor in qualitative research: the assess-

ment of trustworthiness. Am J Occup Ther 1991;45:

214–222.

46. Coombes I, Mitchell C, Stowasser D. Safe medica-

tion practice tutorials: a practical approach to pre-

paring prescribers. Clin Teach 2007;4:128–134.

47. WeeksG,Marriott J. Collaborative prescribing: view

of SHPA pharmacist members. J Pharm Pract Res

2008;38:271–275.

48. Shah B, Chewning B. Conceptualizing and measur-

ing pharmacist-patient communication: a review of

published studies. Res Soc Admin Pharm 2006;2:

153–185.

49. Stoudemire A, Thompson JL. Medication non-

compliance: systematic approaches to evaluation

and intervention. Gen Hosp Psychiatry 1983;5:

233–239.

50. Perkins O. Predictors of noncompliance in patients

with schizophrenia. J Clin Psychiatry 2002;63:

1121–1128.

51. Janis IL. The role of social support in adherence to

stressful decisions. Am Psychol 1983;38:143–160.

52. Schwartzberg JG, Cowett A, VanGeest J, Wolf MS.

Communication techniques for patients with low

health literacy: a survey of physicians, nurses, and

pharmacists. Am J Health Behav 2007;(31 suppl 1):

S96–S104.

53. Dyck A, Deschamps M, Taylor J. Pharmacists’ dis-

cussions of medication side effects: a descriptive

study. Patient Educ Couns 2005;56:21–27.

54. Mesquita AR, Lyra DP Jr, Brito GC, Balisa-

Rocha BJ, Aguiar PM, de Almeida Neto AC. Devel-

opingcommunication skills inpharmacy:a systematic

review of the use of simulated patient methods.

Patient Educ Couns 2010;78:143–148.

55. Zweber A. Cultural competence in pharmacy prac-

tice. Am J Pharm Educ 2002;66:172–176.

56. Pharmacy Council of New Zealand. Cultural compe-

tence standards; 2008. Available at: http://www.phar

macycouncil.org.nz/cms_show_download.php,id¼57.

Accessed 12.01.10.

57. Baqir W, Smith J. Why pharmacist prescribing

appears to be floundering. Br J Clin Pharm 2010;2:

150–151.

58. Baqir W, Clemerson J, Smith J. Evaluating pharma-

cist prescribing across the north east of England.Br J

Clin Pharm 2010;2:147–149.

192 Wheeler et al. / Research in Social and Administrative Pharmacy 8 (2012) 179–192

59. Latter S, Blenkinsopp A, Chapman S, et al. The

evaluation of nurse and pharmacist independent pre-

scribing (ENPIP) study 2008-2009; 2009. Available

at: www.npc.co.uk/events/5thnon_medpresconf/

presentations. Accessed 29.11.10.

60. Hale A, Coombes I, Stowasser D, Nissen L. Evalua-

tion of non-medical prescribing. Aust Health Rev

2011;35:36.

61. Feetam C, Newton G. Pharmacist prescribing in

mental health. Hosp Pharm 2004;11:76–77.

62. LincolnYS,GubaGE.Naturalistic Inquiry.Newbury

Park, CA: Sage Publications; 1985.

63. Walker RA, Martin S. Demographic profile for

Waitemata DHB: An analysis of the 2006 Census.

Auckland, New Zealand: Waitemata District Health

Board; 2007.

64. Oakley-Browne M, Wells J, Scott K, eds. Te Rau

Hinengaro: The New Zealand Mental Health Sur-

vey. Wellington, New Zealand: Ministry of Health;

2006.

65. Robson B, Harris R, eds. Hauora: Maori Standards

of Health IV. A Study of the Years 2000-2005.

Wellington, New Zealand: Te Ropu Rangahau

Hauora a Eru Pomare; 2007.