Exploring the Factors Influencing Pharmacist Prescribers in Hospital Settings: A Realist Evaluation to Optimise Practice and Education

Background The General Pharmaceutical Council has introduced new training standards for pharmacists, mandating a prescribing qualification for all newly qualified pharmacists by 2026. Research shows prescribing pharmacists improve patient safety and outcomes, but most studies focus on quantitative data, lacking insights into contextual factors like organisational culture and interprofessional collaboration that shape prescribing practices. This study will fill a gap in understanding the influences on hospital pharmacists' prescribing practices in the UK. It aims to develop a Programme Theory (PT) for an ideal system where prescribing pharmacists can optimise practice by examining both observable competencies and underlying causal mechanisms. Objectives This research aims to: Identify and analyse key factors from the literature and practice that influence prescribing practices in hospital settings. Examine how organisational and cultural factors affect prescribing practice sustainability. Investigate collaborative practices between PPs and other healthcare professionals. Determine essential RPS competencies for optimised practice. Map workflows to identify inefficiencies and improvement opportunities. Develop a PT that defines critical elements of an optimal system for hospital PPs, offering policy and curriculum recommendations to enhance PPs' impact on patient safety and healthcare quality. Methods Workstream 1 is a realist synthesis of secondary literature, aiming to identify the context-mechanism-outcome configurations (CMOCs). This will provide a structured, evidence-driven basis for developing an initial programme theory (PT) to guide the study. Workstream 2 will involve an ethnographic study with non-participant observation of prescribing pharmacists working in adult inpatient settings across four NHS hospitals. This ethnography will not only inform an interview guide but also test and refine the PT developed in Workstream 1 by examining CMOCs in real-world settings. Interviews will then be conducted with a diverse group of stakeholders, including newly qualified and experienced prescribing pharmacists, managerial staff, and regulatory bodies. By integrating findings from the ethnography and interviews, a realist evaluation in Workstream 2 will refine and validate the PT. Realist depth analysis will identify underlying causal mechanisms at multiple levels, from individual behaviours to broader systemic factors. Framework analysis will map the CMOCs to the RPS's Prescribing Competency Framework, aligning findings with the professional standards and competencies required for effective prescribing. Process mapping will identify bottlenecks, interacting agents, and optimal pathways for improving prescribing practices in hospital settings. Together, these methods will contribute to finalising PT, ensuring it accurately reflects the complexities of prescribing pharmacists' roles and their work environments. Timelines for Delivery (months) 0-18: realist review and initial PT development 7-9: ethics approval 10-12: participant recruitment 13-18: data collection 19-24: data analysis 25-36: thesis write up, dissemination, preparation for viva and submission Anticipated Impact and Dissemination A refined PT offering actionable insights to optimise prescribing pharmacists' roles in hospital settings, informing organisational policies and educational frameworks. This PT will serve as a foundation for future research and interventions to enhance PPs' integration and effectiveness in healthcare. Results will be shared through publications, conferences, higher education, social media, and professional networks, shaping the future of pharmacy practice in the UK and beyond.