Experiences,challenges,perceptions and facilitators associated with paramedic medication prescribing: A scoping review

Abstract

Introduction

The evolving role of paramedics now encompasses the ability to prescribe medication. The development and further implementation of this capability should be informed by existing experiences of paramedics capable of medication prescribing and relevant literature.

Aims

This scoping review aims to explore paramedic experiences and perceptions of medication prescribing, identifying challenges and facilitators to inform future policy and practice.

Methods

A scoping review methodology was employed, adhering to the JBI's framework. A search of six electronic databases, and grey literature sources was conducted. Inclusion criteria focused on studies exploring paramedic prescribing experiences, perceptions, and impacts on the healthcare system. Data extraction and descriptive content analysis was performed.

Results

The database search yielded 193 non-duplicate articles, with 36 meeting the inclusion criteria. Grey literature searches found four additional documents. Key categories generated included the importance of mentoring, a sense of vulnerability and frustration and the importance of supportive systems and role understanding. Mentorship was crucial for building confidence and competence, while role ambiguity and systemic barriers were challenges. Systemic barriers included difficulties in accessing patient histories and outdated or incompatible IT systems. Administrative hurdles, including cumbersome regulatory requirements and limited recognition of their prescribing role, further complicated practice. The fear of litigation was a concern, heightened by inadequate guidelines and support systems. Robust organisational policies and comprehensive legal frameworks were highlighted as crucial, though often perceived as insufficient. Facilitators included strategic leads and multidisciplinary collaboration, enhancing skill integration, and support within organisations.

Conclusion

This review highlights the critical need for structured support, clear role definitions, and robust legal frameworks to empower paramedic prescribers. Addressing technological and systemic barriers will be essential for the successful integration of prescribing roles within paramedic practice.

Keywords

non-medical prescribing independent prescribing paramedic practice advanced practice paramedic prescribing

Editor in Chief: Paul Simpson Deputy Editor: Veronica Lindström

Introduction

The continuing development of the paramedic profession has increasingly seen paramedics working in a variety of settings beyond emergency ambulances, including in advanced practice roles.¹ This shift reflects broader trends in healthcare aimed at improving accessibility and efficiency to community health needs.^1,2 Within these roles, paramedics will typically work autonomously but within a wider multidisciplinary team, supporting patients across the health and social continuums of care.³ Ongoing integration and development of these roles has led to increasing interest in the potential benefits they may provide, including prescribing responsibilities.

The introduction of advanced practice roles has also occurred in other professional groups. In the United Kingdom, nurses and pharmacists have established authority as non-medical prescribers (NMP), that is, prescribing initiated by a health professional other than a medical doctor or dentist.⁴ In 2018, legislation extended this framework to advanced practice paramedics in the United Kingdom (UK).^5–7 NMP is distinct from possessing or providing medication in ambulance practice, which is generally governed by ambulance service permits and strictly tied to the bounds of employment.⁷ Prescribing, by contrast, enables paramedics to initiate, adjust, or cease medication from within a formulary.⁸ While prescribing decisions remain guided by best practice and organisational policy, prescribers exercise their clinical judgement to determine which treatment may be appropriate in a given situation.^8,9

In their work as NMP, paramedic practitioners support the management of acute and chronic conditions, palliative care, with scope to prescribe and deprescribe medicines such as antibiotics and analgesics.¹⁰ NMP has become a key feature of some healthcare systems, particularly those where the burden of chronic disease and ageing populations increasingly means that demand for primary care exceeds the organisational capacity of Medical Practitioners specialising in primary care, commonly known as General Practitioners (GPs).¹¹ There, NMP has facilitated timely access to medication and improved patient outcomes, and can be a cost-effective solution.¹¹ Since its introduction in the UK, the formulary available to paramedic prescribers has expanded, including a restricted list of controlled drugs, increasing their potential to contribute to patient care.^12,13

Reflecting on the UK experience of introducing paramedic NMP is useful for healthcare systems elsewhere, and can help when considering the impacts the skill may have on paramedic practice, patient experience and the healthcare system.^12,13 In Australia, where workforce shortages in primary care and disparities in access remain particularly acute in rural and remote areas, similar pressures have created demand for innovative workforce solutions.¹⁴ This makes it timely to consider what lessons may be learnt for services around the world considering implementing their own paramedic prescribing programs.

Although there is much to learn from longer established NMP professions such as nurses or pharmacists, paramedic prescribers will have unique experiences due to the location of their work, educational backgrounds and structures within which they operate.¹² For these reasons it is important to explore what has been published to inform ongoing work in this space. In addition to exploring the implementation process, it is imperative to assess the various modes of prescribing and access to medications, as these factors have been seen to significantly influence paramedics’ capacity to effectively fulfil their roles.^13,15,16 While paramedic prescribing has many facets, such as the provision of blood products or medical devices, this review focuses on prescribing activities relating to licenced medicine. Evaluating this aspect individually is essential for informing policy decisions and optimising patient care outcomes. As this is an evolving area of research a scoping review was determined to be most appropriate due to the wide variety of evidence and because of the need to identify key concepts relating to paramedic prescribing.¹⁷ This review aims to explore the experiences and perceptions of paramedics who prescribe medications, as well as the enablers and barriers they encounter. In doing so, it examines the broader context in which prescribing occurs, including how paramedics provide medications, the implementation of NMP pathways, and how prescribing has influenced paramedic roles and practice.

Method

Due to the novelty of paramedic medication prescribing, and the relative dearth of literature on initial searching, a scoping literature review was selected as an appropriate method.^17,18 Specifically, we sought to explore the breadth of existing literature surrounding paramedic medication prescribing and to identify knowledge gaps and their implications for practice. The JBI framework for scoping reviews was used in conjunction with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.¹⁹

Research question

The research question addressed in this scoping review was intentionally broad, to ensure that the concepts at the core of the investigation were captured. This approach allowed researchers to gain a deeper understanding of paramedics’ and policymakers’ experiences with non-medical medication prescribing by examining a wide range of literature. A research question for this review was created using the Population, Concept, Context (PCC) approach; specifically asking: ‘what is known about the experiences and perceptions of paramedic medication prescribers and the facilitators or barriers they encounter?’. To clarify each element of the PCC, the Population includes practicing paramedic medication prescribers (and, where relevant, policymakers or educators in similar systems); the Concept examines the experiences, perceptions, challenges and facilitators surrounding paramedic prescribing; and the Context refers to the healthcare environments in which paramedics practice in a professionally autonomous capacity. This framing allowed us to comprehensively explore the breadth of published evidence on paramedic prescribing, ensuring the inclusion of relevant system, practitioner and patient-related factors.

Search strategy

A search strategy, as seen in Table 1, was developed in accordance with the JBI recommended three-step approach for scoping reviews.¹⁸ First, we conducted an initial search in two databases (CINAHL and Medline) using broad paramedic and prescribing terms. Context terms reflecting autonomous paramedic practice were initially trialed but provided limited results. We then reviewed the titles, abstracts and keywords of key articles to identify additional paramedic-related synonyms (e.g. “advanced paramedic,” “paramedic practitioner,”) that may be used internationally. Second, we refined our search strategy in consultation with a medical librarian, who provided peer review of the draft strategy in line with the PRESS checklist.²⁰ The final search excluded context terms to capture a broader evidence base and reflect the variety of settings where paramedic prescribers are known to work. Third, we implemented this final search strategy, across six databases (CINAHL, EMBASE, Medline [OVID], ProQuest, Scopus, and Cochrane) from 1 January 2015, to 2 April 2025. We also performed grey literature searches to capture policy documents, unpublished theses and other relevant textual materials. This included targeted searches in Google, Google Scholar, the Ambulance Research Repository (AMBER) as well hand searches of paramedic-focused journals that were not indexed in our primary databases (International Journal of Paramedicine, South African Journal of Prehospital Emergency Care, and Irish Journal of Paramedicine). We reviewed the first 200 results for Google, Google Scholar and AMBER, as well as all generated from initial database searching were screened. Any item meeting our inclusion criteria was retrieved in full text for further assessment. The search strategy was adapted to each database's requirements, though keywords remained unchanged (see Supplemental Tables 2–7 for database-specific strategies). The protocol, including the search strategy, was registered prospectively with the Open Science Framework under the identifier: doi 10.17605/OSF.IO/TW5R6.17.²¹

Table 1.

OVID search strategy.

1. paramedic*.mp or Paramedics/

2. prescri* authority.mp OR drug prescri*.mp OR drug dispens*.mp OR drug dispens*.mp OR independent prescri*.mp OR non medical prescri* mp OR prescri* authority.mp OR professional autonomy

3. 1 AND 2

Eligibility criteria

We developed a broad set of inclusion and exclusion criteria, balancing the need to capture relevant literature with the requirement that each article align with the review's focus on paramedic prescribing within a professionally autonomous model of paramedic care.

Inclusion criteria

We included peer-reviewed articles, commentaries, policy documents, opinion pieces, discussion papers and conference abstracts published in English. We also considered further grey literature (government reports, professional body guidance or other relevant textual sources) identified through systematic grey literature searches. Items were eligible if they:

Explored paramedic medication prescribing experiences, perceptions, implementation or outcomes (including barriers and facilitators).

Focused on paramedic practice in a healthcare system where paramedics operate as regulated, autonomous practitioners.

In determining whether a given context had “professionally autonomous” paramedics, we examined official national or regional legislation, regulatory frameworks and professional registration structures. This meant including systems such as the United Kingdom, Australia and other regions where paramedic practice is recognised formally, and paramedics have ‘professionalisation, self-regulation, national registration and tertiary/university entry to practice standards.’²² It also means they can engage in clinical decision-making independent from continuous physician oversight.²²

Exclusion criteria

We excluded:

Literature describing paramedic roles in countries or regions where paramedics lack professional self-regulation or cannot independently assess and treat patients (e.g. strictly protocol-based systems requiring real-time physician authorisation).

Non-English articles or items where full text could not be retrieved despite all reasonable attempts. For example, a record would be excluded if only a preview was available and the complete record could not be retrieved. However relevant short form articles or conference abstracts would be included as they formed the entirety of the record.

Items that did not directly address paramedic prescribing (i.e. only addressed prescribing by other non-medical professions, or did not discuss medication prescribing at all).

Newspaper articles, and general-interest magazine articles.

Screening process

To increase consistency among reviewers, all reviewers screened the same 25 initial publications, discussed results, and any amendments made to ensure understanding of screening criteria. The same process was undertaken during data extraction. Literature was then independently screened by title and abstract in Covidence, an online screening and data extraction tool, or by hand, for grey literature. This was done by two members of the research team (KA and LM), with conflicts resolved by a third author (BS). Full text screening was then conducted by the same authors and process.

Data extraction

A data extraction tool was created and piloted in an Excel spreadsheet by the lead author (KA) and was then tested by another member of the team to ensure it captured the necessary data (SB), please see Supplemental Table 8 for data extraction table used.¹⁸ Data was extracted by two authors independently (KA and SB) with conflicts resolved by a third author (BS). Descriptive statistics were employed to appropriately summarise the data, alongside a narrative description of the results, summarising the populations, study design (where applicable), broad findings or key message of the piece. In this review, articles were charted and data extracted on several aspects where applicable: paramedic education, author, year of publication, country, methodology and study population, prescribing ability, barriers, facilitators, experiences or perceptions, and gaps identified.

Data analysis and presentation

In line with JBI's approach to scoping reviews, descriptive content analysis provided a flexible yet systematic approach for classifying, summarising and interpreting the extracted textual data. Data was codified in Excel to allow for this descriptive content analysis, please see Supplemental Table 9 for coding tree details.¹⁸ Firstly, papers were categorised based on the principal issues identified using semantic inductive coding, and further descriptive content analysis of study findings pertinent to the objectives of this review was completed to explore, summarise and report qualitative data.²³ One researcher (KA) independently reviewed and coded each included text line-by-line at the semantic level, noting recurring concepts and creating initial codes. Authors then met to collate codes into overarching categories. We applied Lincoln and Guba's trustworthiness criteria²⁴: credibility, confirmability, dependability and transferability to ensure rigor in content analysis. Table 2 outlines how these criteria were addressed.

Table 2.

Strategies to ensure trustworthiness in descriptive content analysis.

Criterion	Strategy
Credibility	We included multiple studies with varied methodologies and settings, ensuring a breadth of perspectives on paramedic prescribing. A researcher independently coded text segments, then discussed coding decisions and interpretations to develop final categories with the authorship group.
Confirmability	Researchers documented assumptions and reflections throughout the coding process. Detailed notes and coding records were maintained, providing a transparent link between original text and final categories.
Dependability	Researchers reviewed the coding and category generation to ensure consistent application of categories across extracted data.
Transferability	We explicitly documented the included texts in tables to provide context in which paramedic prescribing occurred, allowing readers to judge how or whether the findings apply to their own settings. Categories were illustrated with linking references to the supporting texts.

Quality assessment

A quality assessment of the included literature was completed using the respective JBI critical appraisal tools, and results are included in Table 3.

Table 3.

Characteristics of included studies identified.

Author(s)	Country	Year of publication	Article type	Study design	Number of participants	Quality analysis	Focus
Bedson and Latter⁵¹	England	2018	Journal article	Cross-sectional survey, framework analysis	78 participants	Include	Investigated the ways in which specialist paramedics are supplying medication, and their views on independent prescribing.
Bedson²⁵	England	2021	Journal article	Opinion piece		Include	Discussed some of the unique considerations and challenges that are associated with non-medical prescribing in the context of paramedic emergency care.
Bedson⁹	England	2021	Journal article	Opinion piece		Include	Discussed the importance of evidence-based prescribing practice for paramedic prescribers, as required by the Royal Pharmaceutical Society, and outlined tools that support this practice.
Bedson et al.^49,53	England	2024	Conference abstract	Mixed methods	Not stated	Include	Overview from the ‘Dragon's Den’ conference presentation, which presented their mixed methods investigation into the benefits and limitations of paramedic independent prescribing in emergency and urgent care, exploring facilitators or barriers that might influence implementation and delivery.
Best and Taylor²⁶	England	2021	Journal article	Online survey, mixed methods	63 participants	Include	Reported part of a larger study that explored how paramedics are implementing their prescribing qualification in practice. Investigated whether paramedic independent prescribing is occurring as it had been anticipated to and considered workforce demographics and occurrences of prescribing.
Booker and Voss³⁹	England	2019	Journal article	Opinion piece		Include	Examined the role of paramedic prescribers in primary care settings, especially general practice (GP) clinics, and how further work is needed to evaluate and ensure its cost and resource effectiveness.
Bowles²⁷	England	2021	Journal article	Opinion piece		Include	Considered various factors that paramedics should be aware of when writing a prescription, including legal requirements, common errors, best practice and possible solutions.
Burns²⁸	England	2021	Journal article	Opinion piece		Include	Discussed the role that paramedics, particularly those in advanced clinical roles who can independently prescribe, can contribute to primary care and home visits.
Carey and Stenner⁴⁰	England	2020	Journal article	Opinion piece		Seek further information	Introduced the updated ‘Preparing to Prescribe’ toolkit. The toolkit aims to provide consistent pre-course information, and provides resources for healthcare professionals, non-medical prescribing leads, organisations, and universities to support implementation of non-medical prescribing in practice.
Christie⁴¹	Scotland	2015	Journal article	Opinion piece		Seek further information	Suggested the potential benefits that independent non-medical prescribing could have for both the paramedic profession and patients.
Clarke³⁶	England	2019	Journal article	Semi structured interviews, descriptive phenomenology	8 participants	Include	Explored the experiences of paramedics who moved from working in pre-hospital settings to emergency department roles. A lack of access to medications presented a significant barrier to practice created a disparity between paramedics and their nursing counterparts. Independent prescribing was anticipated to partly address this.
Dean⁴²	England	2018	Journal article	Opinion piece		Include	Suggests introducing NMP for paramedics will improve care by reducing visits to hospital, improve primary care pathways, and continue to contribute to multidisciplinary teams.
Dixon¹²	England	2020	Journal article	Opinion piece		Include	The author considered their own experiences as a paramedic prescriber and challenges they have encountered in practice such as the then inability to prescribe controlled drugs, they then discuss potential solutions and possible future directions.
Dixon²⁹	England	2021	Journal article	Opinion piece		Include	Discussed independent prescribing for paramedics in primary care settings, including the various resources to inform decision making, remote prescribing considerations, and scope of practice.
Duffy and Jones³⁷	England	2017	Journal article	Semi structured interviews, thematic analysis	6 participants	Include	Aimed to establish the views of paramedics on independent prescribing, concluded that paramedics already give a rounded healthcare approach to their patients, this would only be enhanced by prescribing rights, which would also create new career opportunities and add professional credibility.
Edwards et al⁴³	England	2020	Journal article	Opinion piece		Include	‘Better Practice’ that examined potential barriers to early adoption of paramedic independent prescribing in primary care, including common pitfalls prior to training and provided seven practical steps for paramedics considering pursuing non-medical prescribing training.
Edwards et al⁸	England	2022	Journal article	Scoping review		Include	Papers that explored the views of nurse, physiotherapist, pharmacist, and paramedic non-medical prescribers working in primary care were examined to identify barriers and facilitators influencing implementation of independent prescribing.
Evans et al³⁰	England	2021	Journal article	Scoping review		Include	Established a baseline of evidence on advanced care practitioner roles in the United Kingdom (UK), including their outcomes, impacts, and implementation challenges.
Flavell³¹	England	2021	Journal article	Case study		Include	Used a fictitious scenario to consider medication and prescribing errors which may be relevant to paramedics as independent prescribers and outlined possible legal implications for practice.
Gallagher³²	England	2021	Journal article	Opinion piece		Seek further information	Discussed existing legislative mechanisms that exist in the UK, and how the author believes these do not necessarily pose the obstacle that some believe them to be.
Graham-Clarke et al⁵⁴	England	2019	Journal article	Systematic review		Include	This review focused on policy and consultation documents that examined independent non-medical prescribing in the UK, following its implementation and integration into the National Health Service (NHS).
Griffin⁴⁴	England	2015	Journal article	Opinion piece		Include	Suggested that introducing independent prescribing may help to address demand on health care services, cost-efficiency savings, and overcome resource challenges.
Hansard Report⁵⁵	England	2023	Grey Literature	Parliamentary Paper		Include	A transcription from the UK Parliament House of Lords when the legislation to expand the prescriptive scope to include a limited list of controlled drugs for paramedic prescribers was discussed.
Harrison⁵⁶	England	2024	Journal article	Scoping review		Include	This review focused on gaps in medication administration options, the role of paramedic independent prescribing within the autonomous scope associated with paramedic practice, and experiences of practitioners.
Hilton et al⁴⁵	England	2019	Journal article	Opinion piece		Include	Used the anecdotes of paramedic prescribers to discuss the barriers of implementing independent prescribing and potential steps that can be taken to address these difficulties.
Nelson et al³⁵	England	2019	Journal article	Focus groups & semi structured interviews, template analysis	38 participants (2 paramedics)	Include	Explored how three non-medical roles (advanced practitioners, physicians associate, practice pharmacist), were being established in general practice, examining common barriers to implementation, impacts, and unintended consequences.
Nordoff³³	England	2021	Journal article	Fictional case study		Include	Described the principles of patient-centred prescribing, autonomy, and concordance using a fictitious case study to demonstrate how these aspects of prescribing can be achieved by paramedic prescribers.
Peate⁵⁷	Gibraltar (British Overseas Territory)	2021	Journal article	Opinion piece		Include	Reiterated the importance of understanding advanced pharmacology to facilitate safe and effective prescribing by non-medical prescribers, including paramedics.
Proctor³⁸	England	2019	Journal article	Semi-structured interviews, thematic analysis	8 participants	Include	Aimed to understand patients’ experiences and perceptions of paramedics working as non-medical prescribers. Participants had a largely positive view, despite some confusion of how the role operated, and expressed a desire to be more informed about the role.
Pryor et al¹⁶	England	2023	Journal article	Focus group and dyad interview, thematic analysis	9 participants	Include	Aimed to understand the opinions of paramedic prescribers both as students, and then subsequently once qualified and working as prescribers. It noted key themes including role of the paramedic prescriber, expectations, governance, and challenges to practice.
Quaile⁵	England	2018	Journal article	Opinion piece		Include	Described the path to introducing and implementing paramedic prescribing in the UK, including best practice for future practitioners and anticipated benefits to the patient journey, such as reduced delays in care.
Rafael and Ousley⁴⁶	Australia	2017	Grey literature	Opinion piece		Seek further information	Discussed the paramedic prescriber model of care, potential benefits, and how it could be introduced in Victoria, Australia.
Reid⁴⁷	Scotland	2020	Grey literature	Opinion piece		Include	Presented the journey to implementation of paramedic prescribing in the UK, current challenges, and future directions.
Robertson⁵²	England	2022	Journal article	Literature review		Include	Provided an overview of then recently published articles relating to non-medical prescribing, including paramedic non-medical prescribers.
Robertson⁵⁸	England	2024	Journal article	Literature review		Include	Provided a summary of three recent research papers that considered different aspects of paramedic prescribing practice, including prescribing practice and the role in primary care.
Sharman⁴⁸	England	2015	Journal article	Opinion piece		Include	The author outlines the various ways in which independent prescribing may operate for paramedics, explaining the five different options for implementation, as outlined in the NHS consultation document in 2014.
Stenner et al¹⁵	England	2019	Conference abstract	Semi-structured interviews, thematic analysis	17 participants	Include	Explored the experiences of early paramedic prescribers working in a range of healthcare settings in the UK.
Stenner et al¹³	England	2021	Journal article	Semi-structured interviews, framework analysis	18 participants	Include	Explored the experiences of early paramedic prescribers working in a range of healthcare settings in the UK. Identified key benefits such as improved efficiency and safety, and concerns about support and role expectations, particularly in general practice.
Stevens et al⁵⁰	Wales	2024	Journal article	Retrospective cross-sectional design	397 patient records	Include	Compared medication supply between advanced paramedic practitioners using PGDs with prescribing nurses in an out-of-hours service, with a particular focus on medications supplied, how patients received medication, and reasons for seeking prescriber support.
House of Lords Library⁶	England	2023	Grey literature	Parliamentary Paper		Include	Parliamentary discussion paper that considered whether the use of controlled drugs should be expanded to include the use of a limited list of medication for paramedic prescribers.

Consultation

We appointed subject matter experts and stakeholders as consultants throughout the scoping review process to ensure no crucial information or issues were neglected. Accordingly, we consulted three experts: two from the UK (GE, AC) and three from Australia (BS, AU and AB), to ensure adequate breadth of topic exploration.

Results

The literature search identified 213 articles, of which 193 remained after the removal of duplicates. After screening by title and abstract, 52 articles remained, with 36 articles remaining after the full text screening. Four pieces of literature were identified through grey literature search, and citation chaining of included articles resulting in a total of 40 studies included in final review (Figure 1).

Figure 1.

PRISMA flowchart.

Of the included texts, 29 of the 40 studies published within the last five years. Most studies were set in the UK and the most frequent year of publication was 2021.^9,13,^25–34 Of the peer-reviewed articles, qualitative analysis was the most prevalent methodology used in six studies^13,16,^35–38, with a particular use of interviews and focus groups as data collection method. Opinion pieces were also common with 18 included^5,9,12,25,^27–29^{,32,34,39–48}, along with two case studies,^31,33 two mixed methods studies^26,49, and two cross-sectional studies^50,51. Much of this literature centred on the introduction of NMP for paramedic practitioners, with seven articles focusing on this.^{5,39,41,42,44,46,52} These articles were largely anticipatory in nature, discussing what the introduction of the skill may bring for practitioners, patients and the healthcare system.^{5,39,41,42,44,46,52} The characteristics of these, including their place of origin, method, year of publication and key focus are included in Table 3.The settings in which paramedic medication prescribing occurs, as well as paramedic experience and education, were described in various ways across studies and articles. Clinical practice settings were mixed, with paramedic prescribers reporting working across various settings, including emergency departments,^13,25,31 primary care clinics^8,12,13,26 or community care provided by an ambulance service.^26,51 Most reported was prescribers using their skills in a combination of these settings, though it was unclear whether this was in multiple, concurrent, roles or was an amalgamation of previous employment history.^{13,25,26,29,43,51} Reporting on prescriber education varied between articles, however, most paramedics reported either studying for, or having completed a level 7 qualification, which was reported as the educational requirement for independent prescribing in the UK.^{13,16,25,26,51} A smaller section of articles investigated how the role had been implemented and received by practitioners.^{13,16,26,45,51,56}

Three central categories were iteratively identified though descriptive content analysis in this review: (1) the importance of mentoring both during training and beyond; (2) a sense of vulnerability and frustration; and (3) the importance of supportive systems, both at an organisational, and systems level. Table 4 presents the three categories as well as the associated barriers and facilitators identified.

Table 4.

Categories with associated barriers and facilitators for paramedic medication prescribing.

	Barriers identified	Facilitators identified
The importance of mentoring	insufficient access to clinical support lack of mentoring lack of preparedness post training	peer support support from experienced prescribers/General Practitioners access to ‘on call’ clinical support appointment of non-medical prescribing leads ongoing mentoring
A sense of vulnerability and frustration	frustrations with prescribing scope or guidelines increased professional risk/responsibility fear of litigation motivational barriers and increased stress inability to prescribe controlled drugs concerns about remote prescribing lack of parity with other non-medical prescribers
The importance of supportive systems and role understanding	inability to access patient records poor organisational readiness and support poor role clarity technological barriers inappropriate pressure to prescribe failure to utilise prescribing roles to full potential limited role integration conflicts between work and training insufficient ongoing development and unclear career pathway poorly received by General Practitioners	parity with other non-medical prescribers electronic medicines compendium/medication guides to assist prescribing protected study leave paid leave for supervised placements proactive management role clarity provision of structured career pathways and ongoing development

The importance of mentoring

Mentoring was a recurrent topic in the studies included in this review, with the authors of seven articles considering its importance to prescriber development and confidence.^{8,13,16,29,31,43,51} All articles stated that it is a crucial aspect of a paramedic prescriber's training, and noted either its presence as a facilitator, or its absence as a barrier to their success. Three articles mentioned a need for greater placement, with early reviews of the literature establishing that a lack of mentoring was often experienced by candidates undertaking prescriber training.^8,30,35 This was later supported in interviews with practitioners, which identified several key stages of their training during which they perceived mentoring to be particularly important: during initial training, the transition to practice and establishment as a prescriber.^13,16 Mentoring from experienced practitioners was considered to be especially crucial in a building and maintain a practitioner's confidence and development.^8,13 This was particularly noted for complex prescribing for chronic conditions and in the management of vulnerable populations, such as pregnant patients, paediatrics and neonates or those with mental health conditions.^13,29 Results suggested it was the availability and continuity of the mentoring itself, rather than the clinical background of the mentor that had the greatest impact on how paramedic prescribers perceived the benefits of this contact.⁴³ Paramedics enrolled in prescriber courses reported receiving both formal and informal mentoring from GPs, nurse practitioners, and pharmacists.^13,43 This was reflective of the variety of professionals able to act as Designated Prescribing Practitioners, or the designated practitioner responsible for the non-medical prescribing trainee during their practical training.⁵⁹ A mentor's availability was reported as being a key determinant of how impactful their mentoring was perceived to be.^16,43 Paramedic practitioners co-located with a GP in a clinic or emergency department self-reported increased confidence and improvement in their prescribing development as opposed to those who were working in satellite locations requiring phone consultations for clarification.¹⁶

A sense of vulnerability and frustration

Some participants reported increased stress throughout their prescribing journey, which they attributed to a fear of litigation and increased professional risk,^8,13,16,51 pressure to prescribe outside of scope,^13,16,43 as well as systemic barriers. Recurrent structural factors included administrative or technological barriers,^12,13,16,47 including remote prescribing,^{12,13,16,29,31,47} and an inability to access patient records.^{12,13,25,28,31,36,47,51,52,55} The results highlighted an underlying frustration with patient group directions (PGDs), a way of providing medication that has clear, pre-determined criteria to ensure the safe use of a medicine.^14,23,33 Although use of PGDs is not considered prescribing, they were frequently mentioned in the results, with practitioners comparing the use of PGDs to independent prescribing.^42,43,46 Participants reported PGDs to be restrictive and often not reflective of best practice, they reported a preference for NMP where they could exercise increased clinical judgement, and remove a perceived barrier to their practice.^{6,9,16,45,47,51,52,55} Six papers discussed the regulatory limitations around the prescription of controlled drugs, and practitioners noted this compromised patient care and impeded their ability to perform their role.^{6,12,13,29,47,52} In three papers, practitioners referenced a perceived pressure to prescribe outside of their scope, both from those within their organisation and the community.^13,16,43

Understanding the paramedic prescriber role & creating supportive systems

Poor understanding of the paramedic practitioner role from both the public and other health care professionals was consistently cited as a barrier to implementation.^{8,13,16,25,30,35,36,38,43,51} Paramedic prescribers reported limited role integration into existing structures,^8,13 and an unclear career pathway.^13,16,30 Results reflected a lack of workforce planning, although considered, practitioners could not access essential digital systems to write a script.^16,29 Another concern reported was that a lack of workforce planning had led to conflicts between practitioner students’ training, their work commitments and life outside of work.^35,43 There were several protective factors that participants described as improving their workplace prescribing experiences. The creation of Non-Medical Prescribing leads, individuals who work as governance, strategic and operational advocates, was reported to increase workforce integration and role clarity, for both prescribers and their colleagues.⁴³ Membership of a team that reported greater multidisciplinary understanding and cohesiveness were found to be less isolating for practitioners, facilitating greater support, supervision and system improvements.^16,29,43

Discussion

Paramedic prescribers are working in diverse and varied areas of the healthcare system, as is often the case with other NMPs.^8,25,26 Traditionally, paramedics have been perceived primarily as emergency community responders, a perception that has limited their practice and created barriers to their acceptance in non-traditional roles.¹ However, the transition from traditional paramedic roles, to include advanced roles which can often include NMP and expanded responsibilities has highlighted identity issues for paramedics.¹ A poor understanding of the paramedic prescriber role, and confusion among patients and colleagues highlighted a significant barrier to the successful integration of paramedic prescribers.^36,38 Similar experiences were reported amongst community paramedics where researchers found this led to inconsistencies in service provision and job perception for both patients, paramedics and other healthcare providers.³ Here, reaching a consensus on role scope and definition, as well as increasing public awareness, could improve the reception of these ‘non-traditional’ roles. These strategies were similarly successful when pharmacist prescribing was introduced.^3,60,61 Similar strategies can be applied to paramedic prescribers, with the intention to educate the other health professionals as well as the public about prescribers’ qualifications and capabilities. Doing so may help to improve how the role is received and foster trust in paramedic-led interventions.

There appear to be considerable parallels between the introduction of NMP in paramedicine and the previous introduction of NMP to other healthcare professions. Organisational readiness is a key factor in the successful implementation of NMP roles and has been reported by nurse practitioners as both the greatest barrier and facilitator to their success in their prescribing practice.^8,51,62 It is widely acknowledged that challenges including difficulty accessing patient records, technological issues and administrative problems are consistently reported by NMPs, irrespective of their profession.^{8,54,60,62,63} This review suggests paramedic prescribers working in out-of-hospital settings are also affected by these factors; prescribers felt impeded from accessing crucial patient information and tools necessary for safe and effective medication management.^25,28,51 To address these technological barriers, it is essential that paramedic prescribers have access to patient records and the requisite tools to support decision-making, such as on-call clinical support. These interventions are demonstrated to support prescribers to make informed decisions and provide high-quality patient care.^8,62 It is worth noting however, that some of these difficulties have been addressed since being previously reported.⁸ More established NMP professions, such as nurse practitioners, now report fewer administrative and technological barriers than newer prescribing professions, such as physiotherapists.^62,63

Irrespective of how long a profession has had prescribing rights, role recognition and advocacy are crucial in ensuring adequate provision for the role.^8,30 The presence of prescribing leads in UK healthcare organisations is reported to be a facilitator of success for both paramedic and other NMPs at an individual, team and organisational levels.⁶⁴ These leads are usually paramedics, who act as strategic and operational advocates within healthcare teams, and help navigate the complexities of healthcare systems, secure necessary resources and drive policy changes that support the role of prescribers.^64,65 Establishing these lead roles specifically dedicated to overseeing and advancing non-medical prescribing can provide the strategic direction and operational oversight needed to embed these practices within healthcare settings effectively.^64,65 While advocacy from peers is crucial to the successful implementation of prescribing, interprofessional support and mentorship also play a pivotal role.³⁰ Collaborative relationships with other professionals are consistently reported as facilitating success for prescribers.^54,60,62 GPs are commonly sought for mentorship due to their experience prescribing for diverse patient cohorts, however this is anticipated to shift as other professions become established prescribers.^54,60,62 Time spent shadowing GPs was reported by both paramedic and pharmacists prescribers as especially valuable in fostering confidence and knowledge consolidation, and is also noted as foundation aspect of prescriber training by The Royal Pharmaceutical Society's Competency Framework.^13,59,61 This is echoed by literature reporting the experiences of non-medical physiotherapist prescribers, who like paramedic prescribers, found this particularly valuable when prescribing for complex groups.^13,66 Mentoring through less formal ‘buddy’ networks is known to foster confidence in novice prescribers, providing a support network that can offer guidance, shared experiences and aid in the practical application of prescribing knowledge.^8,15

A significant frustration cited by paramedic practitioners often relates to their scope of prescribing practice, and in turn the mode of medication provision being used. This has been previously reported by nurse practitioners, and this review suggests it is echoed by paramedics when using PGDs or supplementary prescribing.^25,36,67 Both professions report that providing medication from lists or directions can be unintentionally restrictive due to obsolescence or rigidity, as these require revision at an impractical rate.^16,52 Although these lists act as a safety mechanism, dependence can restrict practitioners’ ability to fully leverage their clinical expertise and decision-making abilities. The introduction of independent prescribing for advanced practitioners has appeased these concerns and operates alongside supplementary prescribing and PGDs in the UK. Despite this, both professions reported increased stress in new prescribers, with an increased reporting of heightened awareness of inadvertently causing harm, potential for errors, personal accountability and fear of litigation.^8,13,51 Pharmacist prescribers also experienced this, reporting that lack of ongoing support and professional development hindered skill development.⁶⁰ Both pharmacist and paramedic prescribers reported that these factors were further exacerbated by organisational pressures to perform outside of scope contributing to increased anxiety.^8,62 There has been a multifaceted approach to addressing this challenge, with NMP leads not only providing clarification of scope, but also successfully advocating for an expansion of prescribing rights in the UK for paramedic prescribers, and creating prescriber specific continuing professional development (CPD) programmes.^60,64

For paramedics to prescribe safely and effectively, comprehensive training and access to clinical support are essential. An expanded scope may provide part of the solution, however this necessitates review and revision of existing legislation, and is also an opportunity to ensure their prescriptive scope aligns with their healthcare peers such as nurses and pharmacists.⁶⁸ Advanced pharmacology education is crucial to minimise prescribing errors, driven in part by early NMPs’ apprehension to prescribe unsupervised.^34,45,69 This increased training is reflected in the Level 7 module needed to qualify as an independent prescriber, and emphasises the advanced nature of the practitioner role.^26,51,62 As paramedics mature as prescribers, ongoing training and mentoring is vital to the development of robust prescribing practices.^30,69 Physiotherapists have most recently led the call for prescriber specific CPD, noting the need for post accreditation support to address the unique practice experiences and needs of NMPs.⁶³ Opportunities such as this, when coupled with ongoing mentoring, are shown to consolidate prescriber skills and foster longevity and confidence in their practice.^54,68,69 As such, they could be expected to similarly assist paramedic prescribers in their role establishment.

Limitations

The research team acknowledges that excluding literature from countries without an autonomous system of paramedic care may have impacted on the breadth of the literature surveyed. For the scope of this review, it was crucial that any findings were relevant, and transferable to settings which have a professionally autonomous system of paramedic care.²² Other systems of care may be examined in further research. Breadth may have been further impacted as grey literature screening was restricted to the first 200 results to balance feasibility with breadth given the varied terminology in this field. Although this threshold was higher than the 100 result limit often set in scoping reviews, it is possible that relevant studies beyond this point were not captured. While JBI quality appraisal checklists were used for all records, the quality of records should be considered when interpreting findings. Peer-reviewed journal articles demonstrated strong methodological rigour, whereas grey literature lacked consistent reporting and should be considered accordingly.

Future research and considerations

Non-medical prescribing for paramedics has the potential to improve patient access to care, reduce inefficiencies and advance paramedic practice. Ensuring it achieves this, and is successfully integrated into the health system however, requires a whole of system approach. While legislative changes are a necessary first step, they are not sufficient alone and should be supported by policies that promote effective integration into multidisciplinary teams and ongoing prescriber development. Making sure there is robust post qualification support and mentoring, and ensuring the paramedic practitioners role is understood by both the public and other health care practitioners will continue to be key in realising the role's full potential. These steps continue to integrate the paramedic prescriber role into the healthcare system, but may also optimise the delivery of healthcare services, facilitating timely access to medications and improved patient outcomes.

Supplemental Material

sj-docx-1-pam-10.1177_27536386251405906 - Supplemental material for Experiences, challenges, perceptions and facilitators associated with paramedic medication prescribing: A scoping review

Supplemental material, sj-docx-1-pam-10.1177_27536386251405906 for Experiences, challenges, perceptions and facilitators associated with paramedic medication prescribing: A scoping review by Katherine Allman, Lorna Martin, Georgette Eaton, Andy Collen, Sarah Butler, Aliya Usmani, Amanda Burnside and Brendan Shannon in Paramedicine

Footnotes

Acknowledgements

The authors thank Cassandra Freeman – Faculty of Medicine, Nursing and Health Sciences Librarian, Monash University.

ORCID iDs

Katherine Allman

Lorna Martin

Georgette Eaton

Brendan Shannon

Author contribution(s)

Katherine Allman: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Visualization; Writing – original draft.

Lorna Martin: Data curation; Investigation; Resources; Supervision; Validation.

Georgette Eaton: Conceptualization; Supervision; Validation; Writing – review & editing.

Andy Collen: Conceptualization; Supervision; Writing – review & editing.

Sarah Butler: Investigation; Validation.

Aliya Usmani: Conceptualization; Writing – review & editing.

Amanda Burnside: Writing – review & editing.

Brendan Shannon: Conceptualization; Formal analysis; Investigation; Methodology; Project administration; Resources; Supervision; Validation; Visualization; Writing – review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Georgette Eaton is a Deputy Editor for Paramedicine. They played no role in the editorial process, which was conducted in adherence to Paramedicine's editorial policy.

Supplemental material

Supplemental material for this article is available online.

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