Barriers and enablers for midwives using endorsement for scheduled medicines: A literature review

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Contents lists available at ScienceDirect

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Review article

Barriers and enablers for midwives using endorsement for scheduled medicines: A literature review Paula Medway* , Linda Sweet, Charlene Thornton College of Nursing and Health Sciences, Flinders University, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 23 August 2018 Received in revised form 11 November 2018 Accepted 16 November 2018 Available online xxx

Problem: There are currently 429 midwives in Australia who hold the Nursing and Midwifery Board of Australia’s Endorsement for scheduled medicines for midwives. Little is known about how midwives are using the endorsement and what factors impact on its use. Objective: To critically examine the literature to discover what the barriers and enablers are for midwives to use the endorsement. Method: A search was undertaken examining literature published since 2004. Due to a lack of articles specific to midwifery, the search was widened to include literature related to similar non-medical health professions. The search was divided into two streams: accessing the Medicare Benefits Schedule and accessing the Pharmaceutical Benefits Scheme and prescribing. Twenty-six primary articles from 2009 onward met the review criteria. Findings: Although singular barriers and enablers to both streams were identified, many of the themes act as both enabler and barrier. Themes common to both the Medicare Benefits Schedule focus and the Pharmaceutical Benefits Scheme and prescribing focus are that of medical support, scope of practice, ongoing support from health care consumers and management, and endorsement processes. Barriers occur approximately three times more frequently than enablers. Conclusion: Barriers and enablers occur for various reasons including legislative, regulatory, organisational, and the individual’s support for and attitude towards these roles. To overcome barriers and facilitate the success of emerging non-medical extended practice roles, significant buy-in and investment is needed across all levels of the health system. The review highlights a significant gap in knowledge about the endorsement’s use in midwifery. © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Keywords: Endorsement Nursing and Midwifery Board of Australia Midwives Enablers Barriers

Statement of significance

Problem or issue The NMBA endorsement for scheduled medicines for midwives enables Australian midwives access to the MBS and the PBS, and to prescribe according to jurisdictional legislation. Little is known about how, or indeed if, midwives holding the endorsement are using it to its intended capacity, and what the possible enablers and barriers are to its use.

What is already known There are currently 429 midwives in Australia who hold the Nursing and Midwifery Board of Australia’s Endorsement for scheduled medicines for midwives. What this paper adds There is a significant gap in the literature specific to midwifery use of the endorsement, however comparable non-medical health professionals face significant barriers to MBS and PBS access, and to prescribe to their full scope of practice. Barriers occur with nearly three times the frequency as enablers. A whole-of-system approach is needed to support and grow non-medical extended practice roles, including that of the midwife holding the NMBA endorsement.

* Corresponding author at: College of Nursing and Health Sciences, Flinders University, P.O. Box 2100 Adelaide 5001, Australia. E-mail address: medw0005@flinders.edu.au (P. Medway). https://doi.org/10.1016/j.wombi.2018.11.006 1871-5192/© 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: P. Medway, et al., Barriers and enablers for midwives using endorsement for scheduled medicines: A literature review, Women Birth (2018), https://doi.org/10.1016/j.wombi.2018.11.006

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1. Introduction One of the more significant changes to the regulation of the midwifery profession in Australia has been the introduction of the Nursing and Midwifery Board of Australia’s (NMBA) registration standard: Endorsement for scheduled medicines for midwives. A midwife holding this endorsement can apply to Medicare Australia for a Medicare provider number under the Medicare Benefits Schedule (MBS), as well as a prescriber number under the Pharmaceutical Benefits Scheme (PBS).1 With access to these numbers midwives can provide women with Medicare-rebatable episodes of care, prescribe relevant medications (of which 26 are rebatable under the PBS) and order relevant diagnostics. In order to provide these services, the NMBA has set requirements that must be met by midwives applying for endorsement. These include demonstrating a minimum of 5000 practice hours, and undertaking an education program approved by the NMBA that leads to endorsement.1 The midwifery endorsement was originally introduced in 2010, following a series of recommendations by the National Maternity Services Review of 2009.2 The Review highlighted the need to increase maternity care choices for women by developing new models of care, and to expand the roles of appropriately skilled and qualified midwives. In response to the recommendation, provision was made for changes to federal legislation and commonwealth funding arrangements to enable midwifery access to the MBS and PBS. The ensuing registration standard was then developed by the NMBA as a regulatory response. This was part a wider series of reforms being implemented by the federal government at the time.3 While similar services have been provided by midwives internationally since the early 1990s,4 the introduction of the endorsement has enabled Australian midwives to work to full scope of practice in some settings. Data from the NMBA states that there are currently 429 midwives who hold the endorsement for scheduled medicines.5 Despite knowing numbers, little is known about how these midwives are using the endorsement (if at all), and therefore how effective this registration standard is in enhancing the provision of midwifery care in Australia. Use of the endorsement was exclusively confined to privately practicing midwives, until 2017 when the prescribing component of the endorsement was enabled for public sector midwives in the state of South Australia,6 the only jurisdiction as yet to do so. The uptake of midwives applying for endorsement and then translating this into clinical practice has been relatively slow,3 suggesting barriers exist for midwives to use the endorsement to their full scope of practice. The purpose of this literature review is to identify barriers and enablers for midwives to use the NMBA endorsement for scheduled medicines. As there is little midwifery literature pertaining to the subject, the scope of the review has been widened to include literature on comparable non-medical health practitioners who are similarly able to provide Medicare rebatable services and prescribe. It is hoped that this information may be transferable to the midwifery context and contribute to an emerging body of knowledge pertaining to the midwifery endorsement in Australia. 2. Literature review method 2.1. Search strategy and selection process A search was undertaken to identify articles related to barriers and facilitators of midwifery and other non-medical access to the MBS and PBS. Four databases were searched, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, PubMed and Public Affairs Information Service (PAIS) Index.

CINAHL, Medline and PubMed were selected for their extensive collection of biomedical literature, and PAIS Index for its comprehensive public policy-related citations. Search terms such as midwi*, nurse practitioner*, allied health*, non-medical, Medicare Benefits Schedule, prescri*, Pharmaceutical Benefits Scheme, barrier*, facilitat* and enable* were used. The search was divided into two focus areas – access to the MBS; and access to the PBS and prescribing. A summary of the search process appears in Fig. 1 – Prisma chart. Searching for MBS-related articles was limited to primary Australian peer-reviewed research from 2004,7 this being the year when MBS access first became available to non-medical health practitioners, and in recognition that the MBS is unique to the Australian setting.8 As midwives are only able to apply for endorsement after working for a minimum of three years and after undertaking additional education, it was found that the Australian nurse practitioner (NP) role and endorsement processes were most similarly aligned with that of the endorsed midwife, hence this is reflected in the articles contained in the MBS focus. Non-medical prescribing is relatively new in Australia,9 however well-established in comparable Western countries.10,11 As with the midwifery endorsement and unlike medicine, prescribing is not in the practitioner’s initial scope of practice and is usually commenced after undertaking post-graduate study.10,11 For this reason, and due to the low number of Australian-specific findings, the prescribing and PBS-related search was expanded to include non-Australian peer reviewed primary research from 2008-current. Neither focus was restricted by research method. An initial unrestricted search identified 592 articles. Upon removal of duplicate articles and screening using inclusion criteria, 447 were excluded. Titles and abstracts in both foci were screened for topic relevance, revealing 56 articles that were eligible for initial inclusion. These articles were read in their entirety and of these 31 were excluded, as their results were not directly comparable to the midwifery context in Australia. One additional article was found through a snowball screening of reference lists.12 The final 26 articles were summarised and tabled with 14 informing the MBS focus (Table 1) and 12 the PBS and prescribing focus (Table 2). Research technique varied, with 10 articles using quantitative methodologies, seven using qualitative methodologies and nine used a mixed methods approach. All articles included were published post-2009, reflecting the changes in Australian health policy and legislation that have occurred since that time. Notably, the search yielded only one midwifery-specific article, highlighting a critical gap in the literature. 2.2. Critical appraisal of selected studies The ability to critically appraise databased literature is a vital part of the review process in order to interpret and objectively assess potential articles for final inclusion in a completed literature review.13 Each study in this review was critically appraised to assess for quality.12–14 A mixed-methods appraisal tool was adapted15 to identify each article’s strengths and weaknesses. This tool was selected as it enabled the appraisal’s approach to remain consistent across all methodologies. Summaries of the appraised literature can be found in Tables 4–6. Quantitative studies rely on larger sample sizes in order to demonstrate effect and enhance rigour and validity.13 Sixteen of the studies in this review relate to nurse practitioner (NP) practice in Australia, a relatively new role introduced in 2000.16,17 As such, the body of literature related to this is still developing and sample sizes in the studies were often small (n = 1 n = 293), which is a potential limitation of several of the reviewed studies. Similar to midwives, NPs first gained access to the MBS and PBS following

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Fig. 1. Selection of studies.

legislative changes in 2010.18 The introduction of the National Health Practitioners Regulation National Law Act of 2010 (the National Law) changed the regulation of NPs from state and territory-based governance to a common federal system. Some of the included studies were either published or had data collected prior to the introduction of the National Law,19 making direct comparisons before this time difficult. Despite these limitations, it was found that all 26 articles demonstrated an appropriate level of rigour and have been included in the review. Tables 1 and 2 describe in further detail the strengths and limitations of each of the articles. 2.3. Analysis of literature In order to synthesise the literature and identify themes pertaining to barriers and enablers of non-medical MBS and PBS use, a thematic synthesis of the literature was undertaken.20 Coding techniques were employed following multiple examinations of each study’s findings until themes were identified and developed.12,21 Frequency of theme occurrence was calculated according to the number of papers in which the themes were discussed, and these are detailed in Table 3. 3. Findings Review of the literature revealed two overarching findings. First, although there are singularly identifiable barriers and

enablers to MBS/PBS access and prescribing, many of the identified themes can act as both an enabler and a barrier. Second, there were themes that were common to both the MBS focus and the PBS and prescribing focus of the review; that of medical support, scope of practice, ongoing support for the role from both health care consumers and management, and endorsement processes. Barriers occur with approximately three times the frequency as enablers. Table 3 highlights these findings. 3.1. Themes common to both foci 3.1.1. Medical support Medical support (or a lack thereof) was found to act as either an enabler or a barrier. The medical profession has long held dominance in the Australian health care system,22,23 and as such the expansion of non-medical roles undertaking traditionally medical tasks has been met with some opposition both in this country and internationally.24,25 Two of the Australian studies in the review found that medical practitioners were supportive of NP roles. This was in the rural context where it was believed by general practitioners (GPs) that NPs alleviated their workload.26,27 Four of the international studies identified positive support from medical colleagues as being an enabler to non-medical prescribing.28–31 Nine studies found that lack of medical support was a barrier, especially when trying to establish NP roles,24,32,33 and in general opposition to non-medical prescribing.25,29–31,34,35

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No.

Author(s) surnames and year/country

Study aims/purpose

I. Methodology II. Study design III. Data collection methods IV. Data analysis

Sample and setting

Main findings

I. Strengths II. Limitations

1

Currie et al. (2017a) Australia

To describe the effects of CAs on PPNP services. A CA with a MP, or an entity employing MPs, is required in order for the PPNP to access the MBS and PBS.

I. Mixed methods II. Questionnaire III. Online survey IV. Descriptive statistics (quantitative) & thematic analysis (qualitative).

73 PPNPs from varied private practice settings across Australia

I. - First study of its kind in Australia II. - Unknown quantity of PPNPs in Australia so may not be able to generalise findings.

2

Currie et al. (2017b) Australia

To describe the results of a survey examining the care provided by PPNPs that is subsidised by the MBS and PBS.

73 PPNPs from varied private practice settings across Australia

3

Haines and Crichtley (2009) Australia

To gain consensus views on potential NP roles in a rural Australian hospital and identify possible barriers and facilitators to the development of these roles.

I. Mixed methods II. Questionnaire III. Online survey IV. Descriptive statistics (quantitative) & thematic analysis (qualitative). I. Mixed method II. Three round Delphi Study III. 3 rounds of questionnaires: x1 qualitative, x2 quantitative IV. Thematic analysis (qualitative) and descriptive statistical analysis (quantitative)

PPNPs collaborate with MPs in a variety of ways. Some find the CAs helpful in providing support, facilitating care and learning. Organising a CA can be demanding on the PPNP depending on the availability and willingness of the MP. Few PPNPs believed that a CA should be a prerequisite for MBS and PBS access. The current structure of MBS and PBS is complex and restrictive, and sometimes results in an inability to provide a complete episode of care.

4

Helms et al. (2015) Australia

To examine benefits, challenges and financial sustainability of employing a PHC NP in a bulkbilling health cooperative.

5

Keating et al. (2010) Australia

To explore the barriers to the sustainability and progression of the NP role in Victoria, Australia.

6

Lowe and Plummer (2013) Australia

To explore perceptions of the NP role in the Australian healthcare setting, and specifically how supported and sustainable the role is.

Mental health, rural critical care and aged care were the first areas identified for potential NP roles. MPs are supportive a sustainable NP workforce. Co-funding between the state and commonwealth could overcome current funding constraints.

I. Quantitative II. Data analysis of NP's practice and billable MBS items III. Health cooperative's practice dataset IV. Structured Query Language software I. Quantitative II. Questionnaire III. Online survey IV. Descriptive analysis

One NP employed by a bulk-billing primary health care cooperative in the Australian Capital Territory.

The model of care provided is financially viable for the practice. Barriers include restrictive access of MBS items resulting in duplication of services by general practitioners, workflow interruptions and practice inefficiencies.

37 relevant employees of Victorian health services that had received government funding to implement NP roles in Emergency Departments.

I. Mixed methods II. Questionnaire III. Postal survey IV. Descriptive statistics (quantitative) & thematic analysis (qualitative)

A convenience, non-probability sample of 172 participants from three targeted groups: NPs, nurse managers and policy advisors.

Barriers to role sustainability included ongoing government and organisational funding, and a lack of understanding of the NP role. Legislative constraints, endorsement processes and the cost of the Master’s degree required to qualify as a NP were described as barriers to role progression. Despite support for and a positive perception of the NP role, ongoing barriers exist that challenge role implementation, integration and sustainability.

I. - Delphi Method effective for engaging with study participants - Study focused on one hospital, however has implications for the wider rural workforce in Australia II. - Potential bias introduced in the early phase of study as the principal researcher was responsible for education of participants about the research methodology - Inadequate description of how the panellists were identified as being an expert I. - One of the only empirical case reports in Australia on the financial sustainability of PHC NPs. II. - Study of one NP only. - Ethical approval and considerations not identified

I. - One of the first studies of its kind undertaken in Australia II. - Study design prohibited in-depth analysis. - Small sample size. - Research undertaken prior to Federal legislative changes allowing NP access to MBS and PBS. - Ethical approval and considerations not identified I. - Wide range of nursing perspectives gained. - Data supports previous findings of similar studies. II. - Methodology poorly described. - Low response rate - Ethical approval and considerations not identified

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48 experts forming a panel consisting of a wide range of rural health practitioners, consumers and policy makers.

I. - First study of its kind in Australia II. - Unknown quantity of PPNPs in Australia so may not be able to generalise findings.

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Table 1 Summary table of articles: access to the Medicare Benefit Schedule.

To explore the perception by NPs, nurse managers and policy advisors of the integration of NP roles as an Australian nursing workforce reform strategy.

I. Quantitative II. Questionnaire III. Postal survey IV. Kruskal–Wallis 1-way ANOVA test

A convenience, non-probability sample of 172 participants from three targeted groups: NPs, nurse managers and policy advisors.

Policy advisors had a much lower perception rating score than NPs or nurse managers. This may be significant as policy advisors are the main drivers of policy at a state and territory level.

8

MacLellan et al. (2015a) Australia

To provide insight into the complexities facing newly endorsed NPs transitioning to their role.

I. Qualitative II. Descriptive ethnography III. Semi-structured interviews IV. Thematic analysis

10 NPs in the first year of their appointment as a NP, practising in a diverse range of settings throughout Australia.

9

MacLellan et al. (2015b) Australia

To describe the support newly qualified NPs receive from medical colleagues as they transition to their role.

I. Qualitative II. Descriptive ethnography III. Semi-structured interviews IV. Thematic analysis

10 NPs in the first year of their appointment as a NP, practising in a diverse range ofsettings throughout Australia.

10

MacLellan et al. (2016) Australia

To describe the experiences of 10 newly endorsed NPs as they transition to their roles.

I. Qualitative II. Descriptive ethnography III. Semi-structured interviews IV. Thematic analysis

10 NPs in the first year of their appointment as a NP, practising in a diverse range of settings throughout Australia.

11

Middleton et al. (2016) Australia

To examine the profile of Australian NPs and the longitudinal changes seen between the 2007 and 2009 national NP census.

293 NPs working in diverse settings across Australia.

12

Middleton et al. (2011) Australia

To gain a profile of Australian NPs in 2009 and compare this with the profile captured in the 2007 NP census.

I. Quantitative II. Questionnaire III. Survey IV. Repeat measures analysis and McNemar Chisquared tests I. Quantitative II. Questionnaire III. Survey IV. Repeat measures analysis and McNemar Chisquared tests

13

Parker et al. (2014) Australia

To determine what services a health care consumer in Australia will accept from a NP.

I. Quantitative II. Questionnaire III. National online survey IV. Descriptive analysis

14

Scanlon et al. (2016) Australia

To explore constraints associated with the legislation and regulation of NP scope of practice in Australia.

I. Qualitative II. Document search III. Document review IV. Content analysis

NPs have to negotiate a complex and convoluted journey in order to attain NP endorsement. Other health professionals can exert power and influence over NP progress. Determination and resilience are required for the NP to succeed in their role. The NPs were well known to their medical colleagues and had gained their respect over time, enabling rolenegotiation processes with minimal conflict or resistance from the medical practitioners. Medical colleagues were generally found to be collegial and supportive of the NP role. Power, control and political manoeuvering impact negatively on newly qualified NPs who encountered power struggles and deliberate misuse of power from nursing colleagues during their transition. Although the NP role continues to expand and develop in Australia, structural barriers and limitations continue to exist, and previous barriers to the NP role had not been addressed with time. Barriers to full implementation of the NP role had reduced marginally between the censuses but remained high. Not all nurses who hold the NP endorsement are working in roles where they are enabled to practice as a NP. Health care consumers in Australia have had little exposure to or understanding of NP care provision. Despite this, they are accepting of a wide range of NP services. Patients with a higher income are less accepting of NP care. Factors determining NP scope of practice such as education, clinical experience and endorsement requirements are straightforward. The context of practice and jurisdictional differences often hinder NPs working to their full scope of practice. The practical expression of NP scope of practice is therefore different to the way it is described within Federal legislation.

293 NPs working in diverse settings across Australia.

1883 respondents from across Australia. Demographic data revealed that the majority were women aged 25–54 years with tertiary qualifications and an annual household income of more than $80,000 AUD. 63 documents associated with policy, regulation and the operational requirements for NP scope of practice in Australia. All documents were either cited within or referred to by the Nursing and Midwifery Board of Australia (NMBA).

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I. - New knowledge gained on the influences affecting the NP role. II. - Low numbers of policy advisors in sample size. - Non-nurse views not sought. - Ethical approval and considerations not identified I. - Diversity of NP specialties in sample II. - Interviews conducted when the nursing profession in Australia was transitioning from state-based regulation to a single national regulatory body. - Discrepancies between jurisdictional NP standards for practice are not accounted for. I. - Refutes previous research finding MPs hold negative attitudes towards NPs. - Provides new insight into the transitioning NP's relationship with medical colleagues. II. - Legislation governing the regulation of NPs was transitioning at the time the study was undertaken, possibly limiting findings. I. - Diversity of NP specialties in sample II. - Legislation governing the regulation of NPs was transitioning at the time the study was undertaken, possibly limiting findings.

I. - High response rate - Similar questioning enabled a direct comparison with previous survey’s data II. - Recruitment processes in one of the larger jurisdictions were prohibitive, resulting in lower participant numbers I. - High response rate - Similar questioning enabled a direct comparison with previous survey’s data II. - Recruitment processes in one of the larger jurisdictions were prohibitive, resulting in lower participant numbers

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I. - Large number of survey participants II. - Participant demographics not broadly representational of the Australian population at large.

I. - First study of its kind in Australia II. - Does not explore individual experience in comparison to the policy documents reviewed. - Study is based on informed policy analysis rather than specific empirical enquiry.

5

CA — Collaborative arrangement; NP — Nurse practitioner; PPNP — Privately practising nurse practitioner; MBS — Medicare Benefit Schedule; PBS — Pharmaceutical Benefit Scheme; MP — Medical practitioner; PHC — Primary health care.

Author(s) surnames and year/country

Study aims/purpose

15

Cashin et al. (2014) Australia

To describe the confidence of nurse I. Quantitative II. Questionnaire practitioners in their ability to III. Online survey prescribe. IV. Statistical analysis

16

Dunn et al. (2010) To conduct the first national study Australia on the prescribing practices of Australia NPs.

17

Gerard et al. (2015) United Kingdom

To identify and quantify the preference of a patient's choice of health practitioner and what influences this choice when presenting with a minor illness.

18

Hale et al. (2016) Australia

19

Hopia et al. (2017) Finland

To assess patient experiences of, and satisfaction with pharmacist prescribing in two collaborative doctor-pharmacist settings in Australia, in order to identify potential barriers to the implementation of pharmacist prescribing. To describe enablers and barriers to the growth of prescribing confidence for nurses and midwives undertaking a prescriber education course.

20

Kelly et al. (2010) To explore the barriers to practice United Kingdom nurses gaining a qualification to prescribe.

21

Kroezen et al. (2014) The Netherlands

To gain understanding of the views of RNs, nurse specialists (holding a Master of Advanced Nursing Practice), and medical practitioners in relation to nurse prescribing in the Netherlands.

I. Methodology II. Study design III. Data collection methods IV. Data analysis

I. Mixed method II. Questionnaire III. Online survey IV. Descriptive statistics (quantitative) & thematic analysis (qualitative). I. Quantitative II. Discreet choice experiment III. Patient survey IV. Multinomial logit model of statistical analysis

Sample and setting

Main findings

A strong correlation exists between years the NP has been endorsed and confidence to prescribe. NPs were more confident to commence a new medication than alter or adjust medications prescribed by another health professional. 68 endorsed NPs and 64 Australian NPs prescribe less than NPs practicing in comparable settings NP candidates from internationally. across Australia 209 NPs employed in various practice settings across Australia

451 patients with minor illnesses sourced from 5 general practices in England with NMP services.

I. Quantitative II. Survey III. Patient satisfaction questionnaires IV. Cronbach's alpha coefficient & Spearman's rank correlation test

182 patients in a hospital surgical preadmission clinic + 29 patients in an outpatient sexual health clinic in Australia.

I. Qualitative II. Phenomenology III. Learning diary entries IV. Inductive content analysis

31 nurses or midwives enrolled in a Finnish university undertaking a 14-month prescriber education course.

I. Mixed method II. Questionnaire III. Postal survey IV. Descriptive statistics (quantitative) & thematic analysis (qualitative).

151 nurses working in general practice settings in one county in southern England.

I. Quantitative II. Questionnaire III. Postal and online survey IV. Descriptive analysis using STATA

617 RNs, 375 nurse specialists & 265 MPs recruited from their respective professional associations.

Although patients displayed a strong preference for consulting their own doctor, participants were accepting of NMPs due to their patient-focused attributes. Previous exposure to non-medical prescribing influenced preference. Most patients in both settings were highly satisfied with the consultations with and care provided by the pharmacist prescriber. Patient acceptance of this role should therefore not be a barrier to its implementation in Australia.

Enablers included workplace support, peer networking, hands-on learning, the positive attitudes of medical colleagues and the application of theory to practice. Barriers included unclear job descriptors, inadequate treatment plans and the practicalities around how and when medical consultation should occur. Lack of GP and managerial support, reluctance to take on the additional responsibility of prescribing, lack of financial remuneration for the qualification and external workplace factors which impacted on motivation to prescribe were identified as barriers to gaining a prescribing qualification. All study participants held neutral to positive views on nurse prescribing, and agreed that it benefits the nursing profession. Few concerns were expressed about nurse prescribing having a negative effect on the medical profession.

I. Strengths II. Limitations

I. - Insight provided into NP prescribing confidence. - High numbers of respondents II. - Does not take into account quality use of medicines I. - Provides a baseline dataset for NP prescribing in Australia II. - Small sample size

I. - Evidence-based approach to the questionnaire design based on previous NMP research II. - Unknown representativeness of the sample population I. - Consistent results between both settings II. - Sexual health clinic sample size small - Two different healthcare settings may make generalisation of findings difficult

I. - Length of data collection period - Variety of participant workplace settings - Researchers did not know or interact with the study participants II. - No direct questioning of study participants, analysis of participant diary entries only - Student cohort from one university only I. - Provides insight into a population of nurses where numbers of prescribers are low, but opportunity to prescribe is high. - Supports findings from similar studies. II. - One English county only included in study - Ethical approval and considerations not identified I. - Large scale national survey - Provides a direct comparison between the views of nursing and medical practitioners II. - Low response rate by nurse specialists and MPs - Survey conducted at a time when nurse specialists were authorised to prescribe but RNs were not, possibly influencing survey responses.

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Table 2 Summary table of articles: access to the Pharmaceutical Benefits Scheme and non-medical prescribing.

To explore the experiences and perspectives of one of the first cohorts of nurse prescribers in New Zealand (NZ).

23

Lim et al. (2013) United Kingdom

To explore the role of lead NMPs in the organisations belonging to one Strategic Health Authority (SHA) in England.

24

Maddox et al. (2016) United Kingdom

To explore the factors that influence a NMP's decision to take responsibility for prescribing in primary health care settings.

25

Ross and Kettles (2012) United Kingdom

To ascertain the views of mental health nurse (MHN) prescribers in regards to barriers to independent prescribing.

26

Small et al. (2016) To describe and explore the views Australia of Australian midwives regarding prescribing, including barriers and facilitators to prescribe.

I. Qualitative II. Constructivist narrative approach using a multiple case narrative strategy III. Semi-structured interviews IV. Thematic analysis using ‘Narralizer’ software I. Mixed methods II. Partially structured and in-depth interviews III. Telephone interviews IV. Descriptive statistics (quantitative) & thematic analysis (qualitative) I. Qualitative II. Critical incident technique III. Interviews and focus groups IV. Constant comparison analysis

I. Mixed method II. Questionnaire and purposive sampling III. Self-report survey and a focus group IV. Methodological triangulation

I. Mixed method II. Questionnaire III. Online survey IV. Descriptive statistics (quantitative) & content analysis (qualitative)

10 experienced RNs who had recently gained approval as NPs and accredited to prescribe, working across varied health settings in NZ. 27 non-medical prescribing leads from across one SHA in England

Two main themes were identified: the ‘shifting professional boundaries,' and ‘navigating boundaries of practice.' In their new, postprescribing environment nurse prescribers held positive views of their relationships with medical staff which they described as collaborative and interdependent. The lead NMP play an important role in the support and development and implementation of NMP in England. Clear national guidance is needed to support and sustain the role.

20 NMPs (15 RNs and 5 pharmacists) were interviewed. 3 focus groups held consisting of 10 RNs. All participants worked in primary care settings across England. 33 MHN prescribers completed questionnaires and 12 participated in the focus group. All participants were recruited from various locations across Scotland. 66 midwives who had completed an educational program required to gain endorsement to prescribe. Participants were from a wide variety of maternity care settings across Australia.

NMPs sometimes do not want to take full responsibility for prescribing for their patients, especially those with complex health needs. Lack of access to prescriber education and a lack of support for NMPs in their workplace undermine the NMP's prescribing confidence.

I. - Diversity of sample - Confirms previous research regarding NMP prescribing confidence II. - None identified

Barriers to MHN prescribing include lack of recognition for the role and lack of organisational support. Additional barriers specific to mental health nursing include the perceived effect that prescribing may have on the therapeutic relationship and role conflict.

I. - Methodology choice garnered in-depth analysis II. - Small sample size relative to number of MHN prescribers in Scotland

Midwives view prescribing positively, however only a small number of midwives are able to translate this into practice. Delayed and complex registration processes, practicerestricting drug formularies and a lack of opportunity to prescribe in the public sector were barriers to prescribing practice. Supportive interprofessional relationships, strong personal motivation, confidence and being well prepared through formal education were seen as facilitators to prescribe.

I. - First study of midwife prescribers in Australia II. - Survey only offered to midwives who had completed an educational course and therefore not representative of the wider midwifery workforce

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I. - Information was captured in real time, as the nurses commenced prescribing II. - Low numbers of study participants - All prescribers were NPs so study does not capture the views of other NMPs.

I. - Highlights the importance and necessity of NMP - High participation rate II. - Study confined to one SHA in England (there are 10 in total).

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GP — General practitioner; NP — Nurse practitioner; MP — Medical practitioner; RN — Registered nurse; NMP — Non-medical prescriber; UK — United Kingdom.

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Table 3 Themes from the literature. Focus

Theme

Enablers (Article number)

Barriers (Article number)

Common themes between foci

Medical support Managerial and organisational support Defined scope of practice and role clarity Health care consumer acceptance of role Endorsement processes MBS provider numbers, rebates, and item availability Confidence in prescribing ability Mentoring and clinical supervision PBS formulary access

3, 9, 19, 22, 23, 24 19

1, 6, 15, 16, 20, 21, 22, 23, 24, 25 5, 6, 9, 10, 12, 20, 22, 23, 25 6, 7, 9, 11, 14, 15, 19, 24 17, 18 6, 8, 14, 25, 26 2, 4, 6, 11, 12, 14 20, 24, 25, 26 24,25 2, 6, 11, 12, 26

MBS access PBS access and prescribing

3.1.2. Managerial and organisational support Managerial and organisational support is vital to the establishment and ongoing progression of advanced and extended practice roles, and while one study found that workplace support contributed to competence and confidence,28 nine studies described barriers formed through insufficient support in this regard. A lack of organisational support for ongoing funding of NP roles was identified27,33,36,37 as well as insufficient resourcing,33,36,38 inadequate role development and little promotion of the role.27,29,30 Three studies found that senior managerial nursing staff could be obstructive and make decisions on behalf of NPs or non-medical prescribers (NMPs) without having an understanding of how their role functioned.35,37,39 3.1.3. Role clarity and a defined scope of practice Eight studies found that a lack of understanding of NP and NMP roles within organisations was a barrier to practice.16,27,31–33,35,39,40 When colleagues, management and organisations lacked

4, 13,17, 18

15, 21 19, 22, 23, 24, 26

understanding, or there was not a clearly defined scope of practice, NPs and NMPs found conflict, confusion and a confinement of scope. A possible explanation for this is that these roles are relatively new and are still evolving and developing. 3.1.4. Health care consumer acceptance Four studies found that health care consumers generally accepted the role of the NP and NMP, and were affirming of the services provided and the care given.17,41–43 Health care consumers were able to form effective partnerships and communicate well with NPs and NMPs. In contradiction to these findings, two studies reported that patients expressed a preference for consulting with a medical practitioner, especially in relation to medication management.42,43 3.1.5. Endorsement processes Endorsement processes were unanimously found to be barriers, regardless of profession. Becoming endorsed as a NP through the

Table 4 Evaluation review of mixed method studies. Review criteria 1. Study evaluative overview  Are the aims of the paper stated?  Are the key findings described?  Strengths and weaknesses identified?  Policy and practice implications stated? 2. Study and context (setting, sample and outcome measurement)  Is the type of study identified?  Is geographical and care setting for the study described?  Is the setting appropriate to the research question?  Are the inclusion and exclusion criteria discussed?  Is the selection of the sample described (events, persons, times and settings)?  Is the sample appropriate to the aims of the study?  Is the achieved sample size sufficient for the study aims and to warrant conclusions drawn?  Were the outcome criteria identified? 3. Ethics  Was Ethical Committee approval obtained?  Was informed consent obtained from participants of the study?  Have ethical issues been adequately addressed? 4. Quantitative data collection and analysis  Is the sample described?  Was the sample size appropriate for the analyses used?  Is the data collection method described?  Were the data collection instruments validated?  Were the appropriate test used to analyse the data?  Were the statistics appropriate for the research question and design? 5. Qualitative data collection and analysis  Is the data collection method described?  Is the process of fieldwork adequately described?  Is the description of the data analysis adequate?  Is there adequate evidence provided to support the analysis?  Are the findings interpreted within the context of other studies and theory?  Are the researcher’s own position, assumptions and possible biases outlined? 6. Policy and practice implications  Are the study findings generalisable?  Is the conclusion justified given the conduct of the study?  Are the implications for policy or practice identified?

1

2

3

6

16

20

23

25

26

Y Y Y Y

Y Y Y Y

Y Y Y Y

Y Y N Y

Y Y Y Y

Y Y Y Y

Y Y Y Y

Y Y Y Y

Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y N Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y

Y Y Y

Y N/S N/S

N/S N/S U

Y Y N/S

N/S N/S U

Y Y Y

Y Y Y

Y N/S U

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y N Y N/S Y Y

Y Y Y N/S Y Y

Y Y Y N/S Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y N

Y Y Y Y Y N

Y Y Y Y Y Y

Y Y Y Y Y Y

Y N/A Y Y Y N

Y Y Y Y Y N

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

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Table 5 Evaluation of quantitative studies. Review criteria 1. Study evaluative overview  Are the aims of the paper stated?  Are the key findings described?  Strengths and weaknesses identified?  Policy and practice implications stated? 2. Study and context (setting, sample and outcome measurement)  Is the type of study identified?  Is geographical and care setting for the study described?  Is the setting appropriate to the research question?  Are the inclusion and exclusion criteria discussed?  Is the selection of the sample described (events, persons, times and settings)?  Is the sample appropriate to the aims of the study?  Is the achieved sample size sufficient for the study aims and to warrant conclusions drawn?  Were the outcome criteria identified? 3. Ethics  Was Ethical Committee approval obtained?  Was informed consent obtained from participants of the study?  Have ethical issues been adequately addressed? 4. Quantitative data collection and analysis  Is the sample described?  Was the sample size appropriate for the analyses used?  Is the data collection method described?  Were the data collection instruments validated?  Were the appropriate tests used to analyse the data?  Were the statistics appropriate for the research question and design? 5. Policy and practice implications  Are the study findings generalisable?  Is the conclusion justified given the conduct of the study?  Are the implications for policy or practice identified?

4

5

7

11

12

13

15

17

18

21

Y Y Y Y

Y Y N Y

Y Y Y Y

Y Y Y Y

Y Y Y Y

Y Y Y Y

Y Y N Y

Y Y Y Y

Y Y Y Y

Y Y Y Y

Y Y Y N/A Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y N Y Y Y Y

Y Y Y N Y Y Y Y

Y Y Y N Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

N/S N/S U

N/S N/S U

N/S N/S U

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y N/S N/S

Y Y Y

N Y Y

Y Y Y N/A Y Y

Y Y Y N/S Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y N Y Y

Y Y Y N/S Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Table 6 Evaluation of qualitative studies. Review criteria

Study number

1. Study evaluative overview  Are the aims of the paper stated?  Are the key findings described?  Strengths and weaknesses identified?  Policy and practice implications stated? 2. Study and context (setting, sample and outcome measurement)  Is the type of study identified?  Is geographical and care setting for the study described?  Is the setting appropriate to the research question?  Are the inclusion and exclusion criteria discussed?  Is the selection of the sample described (events, persons, times and settings)?  Is the sample appropriate to the aims of the study?  Is the achieved sample size sufficient for the study aims and to warrant conclusions drawn?  Were the outcome criteria identified? 3. Ethics  Was Ethical Committee approval obtained?  Was informed consent obtained from participants of the study?  Have ethical issues been adequately addressed? 4. Qualitative data collection and analysis  Is the data collection method described?  Is the process of fieldwork adequately described?  Is the description of the data analysis adequate?  Is adequate evidence provided to support the analysis?  Are the findings interpreted within the context of other studies and theory?  Are the researcher’s own position, assumptions and possible biases outlined? 5. Policy and practice implications  Are the study findings generalisable?  Is the conclusion justified given the conduct of the study?  Are the implications for policy or practice identified?

8

9

10

14

19

22

24

Y Y N Y

Y Y N Y

Y Y N Y

Y Y N Y

Y Y Y Y

Y Y N Y

Y Y Y Y

Y Y Y N Y Y Y Y

Y Y Y N Y Y Y Y

Y Y Y N Y Y Y Y

Y N/A N/A Y Y Y Y Y

Y Y Y N Y Y Y Y

Y Y Y N Y Y Y Y

Y Y Y N Y Y Y Y

Y N/S N/S

Y N/S N/S

Y Y N/S

N/A N/A N/A

Y Y Y

Y N/S N/S

Y Y N/S

Y Y Y Y Y N

Y Y Y Y Y N

Y Y Y Y Y N

Y N/A Y Y Y N/A

Y N/A Y Y Y Y

Y N Y Y Y N

Y Y Y Y Y N

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Y = yes; N = no; N/A = not applicable; U = unknown; N/S = not stated.All evaluation tables adapted from Long et al. (2002).

NMBA was described in qualitative data as being fraught with lengthy delays and complex bureaucratic processes that can be difficult for NPs to understand and navigate.3,33,40,44 This was similarly described in the midwifery prescribing paper.3 A British

study describes how endorsement processes undermined NMPs in their confidence to prescribe due to the lengthy time taken between completing a prescriber education course and commencing prescribing in the workplace.35

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3.2. MBS access The MBS is a fee-for-service model that contains over 6000 items claimable by health care providers for their services.22 Six of the Australian NP studies reviewed found that accessing the MBS to provide patient services was both complex and problematic.17,18,33,39,40,45 Under MBS provisions, NPs can only order a limited number of diagnostic services that attract a Medicare rebate.46 The studies thus described service duplication as if the required diagnostic test did not attract a rebate when ordered by the NP, then patients wanting to claim a rebate required a second consult with a GP to order the test. The studies also found that the Medicare rebate received by health care consumers for NP services is inadequate and does not compensate for the level of care provided. Consequently many NPs are required to charge the health care consumer an additional fee on top of the rebate. Services provided by NPs currently receive the lowest rebate of all advanced practitioners.39 A final access barrier to the MBS was that of public sector NPs being unable to obtain a Medicare provider number under the current Medicare provisions. Medicare does not cover the cost of ordering diagnostic services without a valid number in public outpatient settings, meaning the hospital is unable to claim the cost of the service from Medicare. This sets limits on the NP scope of practice in these settings if the hospital is unwilling to absorb the full cost of the diagnostic procedure.18,39,40,45 3.3. PBS access and prescribing 3.3.1. Confidence in prescribing ability Level of confidence was described as having an impact on the practitioner’s prescribing capability. Two of the articles found that confidence in prescribing ability is directly related to time spent prescribing and that confidence comes with experience.25,32 Conversely, a lengthy time taken from prescribing endorsement to prescribing in practice eroded NMP confidence.35 Four studies found that fear was a contributing factor that additionally undermined the NMP’s prescribing confidence.3,31,35,38 This fear was predominantly of making errors and the flow on of consequences that might occur as a result. In the Australian study of midwifery prescribing, midwives voiced their concern through statements such as feeling “nervousness at actually writing a script” and “I stay awake worrying about a script I wrote”.3, p.440 Other reasons for lacking confidence were related to inhibitory local protocols for NMPs34 and feeling underprepared by the education course leading to a prescribing qualification.31 3.3.2. Mentoring and clinical supervision The provision of mentoring and clinical supervision to NMPs has the ability to either enhance or hinder practice. Two of the reviewed British studies identified a lack of mentoring or clinical supervision as being detrimental to NMPs, and that without adequate supervision it is difficult to increase prescribing competence.31,35 These authors indicate that supervision is especially important in the early stages of qualifying as a prescriber. Maddox et al.31 described an incident where through lack of clinical supervision a NMP made a prescribing error that resulted in an adverse patient outcome. As a result, the practitioner ceased to prescribe in similar situations. Conversely mentoring can enhance a prescriber’s practice and improve prescribing capability. Four international studies, and the Australian midwifery study identified that mentoring builds trust between practitioners and enhances prescribing safety.3,28–31 Being mentored helped to consolidate practice and promoted the role of the NMP prescriber to others. Small et al.3 describe how good peer support and mentoring enabled midwives to increase their confidence, which

in turn improved overall job satisfaction, with midwives expressing that they were able to provide a more complete service to women. 3.3.3. The PBS formulary The PBS formulary was only described as a barrier to practice in the literature. Although the PBS provides access to a wide range of government-subsidised medicines, the medicines available for NPs and midwives to prescribe are restricted,47 requiring the consumer to pay full price if they are dispensed a non-designated medication. Five Australian studies found the limited formulary to be a barrier,3,18,33,39,45 restricting the practitioner’s ability to provide care and increasing costs to the health care consumer if they chose to accept a prescription for medicines not listed on the PBS. Two of these studies further identified difficulties in gaining initial access to the PBS.39,45 In the Australian midwifery context, Small et al.3 found that restrictive formularies dictated by jurisdictional poisons regulations compromised a midwife’s ability to provide women with quality care. 4. Discussion The reviewed literature highlighted that there are multiple barriers and enablers to non-medical access of the MBS, the PBS, and to prescribing, with nearly three times as many barriers to practice as there are enablers. It additionally found that identified enablers might also serve as barriers, and vice versa. Although the two main foci of the literature search pertained to MBS access, and PBS access or prescribing, there were five common themes that stretched across both foci, that of medical support, scope of practice, ongoing support for the role from both health care consumers and management, and endorsement processes. This review has also described barriers and enablers to practice specific to the MBS and PBS. The themes identified in the review are many and varied, and occur across the health care system. They can be attributed to complexities associated with legislation, regulation, health care organisations and individual attitudes and beliefs. Australian legislation acts as both a barrier and enabler for advanced practice roles, and in particular the NP. While legislation was enacted in 2010 to allow NPs access to the MBS and the PBS, the legislation limits the available Medicare items and PBS medications.17,18 This has a flow on effect by restricting NPs from working to their full scope of practice. The PBS similarly limits midwives, as there are currently only 26 medications that attract a government subsidy if prescribed by a midwife.47 As well as limiting the individual’s scope of practice, it can limit the health care consumer’s ability to access quality care due to increased service costs, medication costs, and through the duplication of services. This is ironic given that the NP role was originally introduced to assist with medical practitioner shortages, especially in rural areas,44 and that the midwifery endorsement was introduced to increase women’s access to midwives.2 Increasing the range of medicines available for government subsidy when prescribed by midwives and NPs would serve to reduce these issues. Regulation of the advanced and extended practice nursing and midwifery roles is undertaken in Australia by the NMBA.1,48 Applications for practitioners seeking endorsement on their registration are processed by the Australian Health Practitioner Regulation Agency (AHPRA) and then referred to the NMBA for approval.5 The pathway to gain initial endorsement was described by NPs as complex, bureaucratic and delayed.33,44 The midwifery study found that midwives face similar hurdles.3 Since the roles were introduced there have been changes to both the legislation and the standards for practice, which may have contributed to the confusion. Despite this, better communication and greater clarity

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from the regulatory body regarding endorsement processes would assist practitioners though the application process. Organisational and managerial support can greatly impact on the success of advanced and extended practice roles. When investment is made in an NP or NMP role, particularly through the provision of ongoing funding and resourcing, the role is much more likely to succeed and function at its intended capacity. Organisations should provide practitioners with a clearly defined scope of practice and extend this definition to other health practitioners and key stakeholders. As there is often a ‘blurred interface’ between medical practitioner and nurse or midwife advanced and extended practice roles, good communication and education are vital at reducing conflict across all levels of an organisation.27 Individual attitudes likewise have the ability to either positively or negatively influence the success of advanced and extended practice roles. The personal beliefs of medical practitioners, nursing and midwifery colleagues, managers, hospital administrators and even the health care consumers themselves impact on the ability of the practitioner to perform their role effectively. Education provided at an organisational level would assist to promote such roles and provide clarity about scope of practice. Having a ‘champion in the space’ can be particularly effective at combating negativity and positively promoting these roles in the workplace.27,30 Use of the endorsement has until recently been used exclusively by privately practicing midwives (PPMs). South Australia has recently introduced prescribing for midwives holding the endorsement into public sector roles.6 As use of the endorsement begins to expand into roles beyond that of the PPM, support of its use from individuals and organisations will be critical in order for it to grow and flourish in new health care settings. Although comparisons may be drawn between the NP and NMP contexts, a direct comparison to the midwifery context in Australia may be limited. Despite similarity between the legislation governing and regulating practice, neither the international experience of NMPs nor the local context of NPs are directly translatable to NMBA endorsement use in Australian midwifery. A reason for this is because the scope of the midwife is more clearly definable than that of the NP or NMP. The midwife’s role, in the definition of the International Confederation of Midwives, is predominantly to “give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant”.49, p.1 This is in contrast to the definition of the NP as described by the NMBA, whereby a NP is “an advanced practice nurse endorsed by the NMBA who has direct clinical contact and practises within their scope under the legislatively protected title ‘nurse practitioner’ under the National Law”.48, p.3–4 The definition of the NP does not account for the separate specialties contained within nursing, leaving the scope of practice open to interpretation. Scope of practice is likewise described broadly in relation to NMPs, with a plethora of different regulatory authorities and legislation governing the practice locally and internationally.9 As the scope of a midwife is so specific, the MBS mostly provides the range of items needed for the midwife to provide care and order diagnostics within their scope,50 so it is less likely that the MBS places as many constraints on midwives in comparison to NPs. The exception to this is with Medicare rebates, which like NP rebates, provide a low reimbursement to women and their infants for the services provided, in comparison to other health practitioners who provide similar services rebatable by Medicare. This often results in an increased out of pocket cost to the woman,

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which may act as a deterrent for potential users of private midwifery services. Higher Medicare rebates would address this issue. Parallels can be more closely drawn in regards to PBS access and prescribing, and these have already been described by Small et al.3 This however is but one study and additional research needs to be undertaken in this area to provide further knowledge regarding midwifery access of both the MBS and PBS. Contradictions in the literature occurred in relation to health care consumer satisfaction of non-medically provided services, either by a NP or a NMP. While some studies described satisfaction with these roles, other studies stated that the real preference of the patient was to see a medical practitioner.42,43 This may be due to the fact that some services that have traditionally been by provided by medical practitioners can now be provided by NMPs, and in particular the NP. The role of the NP was implemented with the intent to provide high quality care in a timely manner, reduce healthcare costs and assist with service gaps, particularly in rural and remote settings.44 Despite the fact that NP roles have been implemented in Australia since 2000, role growth is slow compared to NP growth internationally,37 perhaps correlating with the slow growth of patient acceptance of the NP. Another explanation may be that with the relatively small numbers of NPs Australia wide, patient exposure to the role is limited.41 Until such a time that NPs are more commonly seen in practice, studies may continue to provide contradictory accounts of acceptance of the role. Australian midwives face similar challenges. A recent study exploring public perceptions of midwives found that while midwives are perceived as caring and supportive health professionals, there is an underlying narrative that sees midwives as assistants in the birth room rather than a lead maternity care professional with a high level of skill and expertise.51 The study hypothesised that this misperception impacts on the ability for women to make an informed choice regarding their maternity care options and may have hindered the uptake of midwifery models of care.51 Unless such perceptions are publically challenged, this issue is likely to remain. 5. Strengths and limitations This paper highlights the lack of available evidence to inform and progress the use of the Australian midwifery endorsement. Good health policy should be informed by evidence, and with little published literature pertaining to the Australian midwifery endorsement, this paper supports the need for further research. This may then provide a deeper understanding of how midwives are using the endorsement and examine how it can be improved. A limitation is that because the NMBA midwifery endorsement unique to the Australian context it was difficult to draw comparisons to the profession in similar countries such as the United Kingdom or New Zealand. 6. Conclusion The purpose of this review was to identify and explore potential barriers and enablers for midwives to use the NMBA endorsement for scheduled medicines. With a dearth of available midwifery literature comparison was sought from similar non-medical professions providing autonomous care. This showed that barriers and enablers occur for a variety of reasons: legislative, regulatory, organisational, and the individual’s personal support for and attitude towards these roles. The review suggests that in order to overcome barriers and facilitate the success of emerging nonmedical advanced and extended practice roles, significant buy-in and investment needs to occur at all levels from within the health system. The review also highlights a significant gap in knowledge

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Please cite this article in press as: P. Medway, et al., Barriers and enablers for midwives using endorsement for scheduled medicines: A literature review, Women Birth (2018), https://doi.org/10.1016/j.wombi.2018.11.006