NURSES AND MIDWIVES EXPERIENCES
Exploring nurses’ experiences of prescribing in secondary care: informing future education and practice
Roslyn Kane, Principal Lecturer, College of Social Science, University of Lincoln, Lincoln, UK.
Telephone: +44 01522 837326.
Aims and objectives. To explore the experiences of secondary care nurse prescribers to establish how prescribing is employed and what its benefits and disadvantages are perceived to be.
Background. Nurse prescribing has developed rapidly since it inception almost 20 years ago and there is a significant body of research evaluating its implementation in primary care. Recent expansion of non-medical prescribing rights has prompted nurses in secondary care establishments to become prescribers. Evaluation of nurse prescribing in this new environment is required, if practice is to be informed and advanced. The lack of such evaluations in the published literature was the impetus for this study.
Design. A cross-sectional qualitative study.
Methods. A convenience sample of nurse prescribers was interviewed using a single broad question to prompt elaboration. Transcribed interviews were analysed using Colaizzi’s procedural steps.
Results. Three main themes emerged from the analysis: motivations behind becoming a nurse prescriber; benefits and limitations of prescribing education and continuing professional development and prescribing in practice.
Conclusion. Nurses felt nurse prescribing offers clear benefits in relation to patient care. Where nurses were not prescribing, finance arrangements between different NHS trusts appear to be a significant barrier to its successful implementation of prescribing in practice. Nurse prescribing is strongly believed to be the domain of the experienced nurse. There is a clear need for ongoing evaluation of all aspects of nurse prescribing.
Relevance to clinical practice. This paper makes key recommendations on the future development and delivery of programmes of education for nurse prescribers and for the delivery of safe and effective prescribing in practice.
Nurse prescribing in the UK, was originally introduced following the Cumberledge Report (DHSS 1986) as a novel way of improving patient care. Restricted initially to community nurses with a small product range, research and political change have supported expansion of prescribing rights to include other professional groups and enabled independent prescribing from the British National Formulary (DH 1989, 1998, 1999a,b, 2000a, BMA & RPSGB 2010).
Some commentators argue that nurse prescribing has been used as a political tool by successive governments, to manipulate power balances between medical, nursing and pharmacy professionals and imply that nurses provide a cheap and effective solution to shortages of doctors (McCartney et al. 1999, House of Commons 2000, Horton 2002). These views however do not respect the degree to which changes in societal values, technological advance and patient benefit have influenced healthcare delivery (Baggott 1998, Giddens 1998, Oughtibridge 1998, Jones 2004). The radical changes in prescribing are therefore argued to reflect the modernisation agenda of the previous labour government in the UK. This commitment to a very different approach to workforce planning and role redefinition was demonstrated in the allocation of £10 million to the implementation of non-medical prescribing education (DH 1998, 2000a,b, 2003a,b,c,d).
Unfortunately, uptake of training appears to have been slow, possibly reflecting the length and intensity of academic courses and the initial restrictions of the Nurse Prescribers’ Formulary to minor ailments, wound and continence management products (Griffiths 2003, Scottish Association of Community Hospitals 2004, NMC 2005). Legislative change has addressed this problem and independent nurse prescribers now have access to most drugs in the British National Formulary, including controlled drugs in specific circumstances (DH 2005, BMA & RPSGB 2010). This change does not extend to all other health professionals, some of whom continue to act as supplementary prescribers (who only prescribe medicines, in partnership with an independent prescriber and the patient using an agreed Clinical Management Plan) (DH 2005, 2011).
The aim of the study was to explore the experiences of secondary care nurse prescribers to establish how prescribing is employed and what the benefits and disadvantages are perceived to be.
The specific objectives were:
- • To conduct a series of in-depth interviews with a purposive sample of nurse prescribers.
- • To explore the views of nurse prescribers on the preparatory prescribing education they received.
- • To explore the experience of nurse prescribers of undertaking the prescribing role.
- • To formulate a set of recommendations to inform future education and practice.
A review of contemporary literature on the impact of nurse prescribing suggests that in primary care it has been well received by patients and professionals alike, who report benefit in terms of access and timeliness. Patient satisfaction, in particular, appears to be attributed to the quality of the nurse–patient relationship (Harris et al. 2004, Lewis-Evans & Jester 2004, While & Biggs 2004, Latter et al. 2005).
The issue of competence concerns both nurses and patients, who believe rigorous education is essential in safeguarding patient safety and confidence. Continuing professional development (CPD) is a key theme in the published literature as is the need for ongoing evaluation (Harris et al. 2004, Latter et al. 2005, Travers 2005). Pharmacological education, in particular is perceived to be insufficient (Banning 2004, Courtenay & Carey 2007). Good medical mentorship and peer support are identified as vital, not only during prescribing education, but as part of ongoing practice (Jones et al. 2007). Prescribers believe this should be supported by employers through formal CPD structures (Otway 2001, 2002).
Negative aspects of prescribing appear to be centred around organisational issues such as, duplication, excessive paperwork, insufficient ongoing educational support and the limitations of the early formulary and are cited as reasons for some nurses either choosing not to or being unable to prescribe (Luker et al. 1998, Luker & McHugh 2002, While & Biggs 2004).
Regarding those nurses who do prescribe, the literature indicates that they do so for their patient group, both appropriately and within the limits of their competence (Luker et al. 1998, Luker & McHugh 2002, Latter et al. 2005, Bradley et al. 2007).
Research in this field demonstrates a high degree of accord in relation to findings and emerging themes, despite a broad range of methodologies and participants. It does not however include any significant evaluative research from the secondary care (acute hospital) setting, due to the novelty of nurse prescribing in this arena. It is therefore the role of nurse prescribers in secondary care that is the focus of this study.
A qualitative approach was chosen to allow in-depth exploration and examination of the experience of nurse prescribers, during their preparatory education and during the process of undertaking their new role. To achieve this, a phenomenological approach was selected as an appropriate tool for data collection and analysis.
The use of a single broad open-ended question was believed to provide a starting point from which the meaning of the experience for that individual would emerge, thus facilitating deeper understanding of the experiences, thoughts and emotions of the participants.
Throughout the research a number of measures were employed to enhance credibility and trustworthiness and reduce bias. In the first instance the use of a phenomenological approach requires the researcher to ‘bracket’ or suspend prior knowledge and presupposition of their own lived experience, thus considering the participant’s description in isolation (Solomon 1988, p. 136).
This approach was complemented by the return of transcripts in their exhaustive form to the participants for authentication prior to the analysis, which was carried out using Colaizzi’s (1978) procedural steps. These measures are believed to ensure the results presented have truly captured the emic perspective of the participants.
Gaining ethical approval
Prior to recruiting participants, ethical approval was granted by the Ethics panel at the University’s School of Health and Social Care Research and Local NHS Research Ethics Committee. Support from the appropriate local NHS Research and Development Department was also secured.
Selecting the participants
Nurse prescribing is a relatively new development in secondary care and consequently there were relatively few nurse prescribers from whom to draw a sample. Approximately, one-third of the 34 nurse prescribers in the NHS Trust, where the study took place, were believed to meet the study inclusion criteria of having been a registered prescriber for over a year. Invitations to participate were sent via the prescribers’ forum. Seven positive responses were received, resulting in six interviews being completed. Although small, the sample size is in keeping with the recommended sample size for this type of qualitative research (Sandelowski 1995). Participants were specialist nurses from five disciplines, working in an NHS Trust’s hospitals in a large rural county in England. Prescribing education had been undertaken at four different universities.
All participants were provided with an information sheet detailing the purpose and nature of the research, study procedures relating to the protection of confidentiality and anonymity and the right to withdraw from the study at any time. All participants provided written consent prior to being interviewed.
Interviews were conducted by the lead author at a venue of the participants’ choice where a quiet, private room was booked by the researcher. The interviews were digitally recorded and later transcribed, to ensure that the experience as described by the participant was accurately captured. Although transcribing was a lengthy process, it enabled immersion in the data and an appreciation of the importance of speech patterns. In some instances, although mentioned only once, the tone of the participant’s voice emphasised the importance of the issue to them. The strength of feeling regarding some issues was also identified by noting repetition of key statements or themes.
Analysis of the data
Data analysis was carried out using Colaizzi’s (1978) Procedural Steps which provides a framework, in keeping with phenomenological research. Meaning statements were clustered into common themes and again referred back to the original commentary for validation, thus ensuring that only the participant’s perception was captured. In following the principles of data reduction all themes were included until a textural–structural description of the experiences of the nurse prescribers as a whole was obtained.
Three main themes and emerged from analysis of the data, each of which is elaborated on below. Transcript data are presented using numbers to denote the views of individual participants.
Theme 1: motivations behind becoming a nurse prescriber
Nurse prescribing education was offered by line managers to the nurses in this study and the reason behind this, some suggested, was that there was no direct cost incurred by the employer at that time. The availability of centrally funded prescribing education therefore appears to have been a significant factor in the uptake of training. There are suggestions however that the motivation was more on the part of the managers than the individual nurses themselves:
5: The Government had given these free places for training and there was this sort of scrabble for all of us to be put into doing it whether or not we needed it.
Despite this, most of the nurses also reported their own positive motivations for agreeing to undertake the course:
6: I thought it would be very useful…add to the total patient experience.
3: The thing that used to hold up the clinic was that I had to queue outside the doctor’s door to get the prescription written.
One nurse described having reservations regarding taking over doctors’ roles, but changed her view completely as the benefits to both patients and members of the prescribing team became apparent.
Theme 2: benefits and limitations of prescribing education and continuing professional development (CPD)
All participants reported key concerns relating to the nature of the education programme they attended. Significant concerns were the intensive nature of the course and the strong focus on primary care:
3: We hadn’t got anything to do with secondary care and it was obvious that the tutors hadn’t a clue about secondary care either.
6: They really weren’t very beneficial to me: sitting in lectures about head lice.
The level of pharmacological education was also consistently reported as being too low, lacking depth and often not relevant to secondary care nurses and therefore considered not to have met expectations:
6: Actual lectures on analgesia were very basic, so they were below the level.
However, there was recognition that courses did cover the nationally agreed principles of prescribing practice (ENB 1998, UKCC 2001, NMC 2006), although the importance of complying closely with national guidance was not always fully appreciated. There were suggestions that education providers were sometimes restricted in the content and coverage of programmes:
1: Their hands are tied by the government.
4: We did an awful lot on accountability and responsibility, which I think was quite good now. At the time I felt that we went through it so many times.
Concerns about variations in assessments and academic credit between institutions were expressed in the interviews. These were viewed as unfair when the endpoint for students undertaking the training was the same i.e. achieving recognised prescriber status:
4: 48 credits at level 3 and some of the others are a lot less credits and to me, a nurse prescribing course should be equal throughout the country, to gain the same qualification.
There was a feeling that although courses did not always meet the expectations of nurses from secondary care, they were reported to equip students with sufficient knowledge and confidence to begin to undertake the role:
1: It proceeded to tick the right boxes for someone to feel confident that I am a practitioner who is responsible enough to be able to prescribe.
A positive benefit of the education was the inclusion of clinical mentorship which appeared to have been successful:
6: He [the mentor] was there, supporting and you know he just helped me with whatever he needed to help.
However, some potential problems regarding mentorship were also alluded to:
1: It certainly won’t work if you can’t work in partnership with the person [mentor]. The person has to be wanting you to do it.
Once qualified, the experiences of nurse prescribers in relation to CPD varied:
3: You know the framework we used when we qualified, I asked some advice from a tutor in [name of university attended], ‘what would you expect us to do in the way of updating?’ and she said ‘do one item at least from each of the competencies each year’. So that’s what I do.
6: I’ve been to quite a few; various study days, conferences.
This haphazard approach and lack of a formal national infrastructure to guide CPD activity was viewed negatively and appeared to be the cause of some frustration.
Transcripts suggested that centralised (National and Regional) dissemination of information pertaining to CPD was poor:
6: There is a lack of communication as to what we should and shouldn’t be doing from the NMC.
Theme 3: prescribing in practice
Variations in the way prescribing theory translated into practice were reported. Only three of the six prescribers were actually prescribing regularly. One had prescribed once, in an emergency situation and the remaining two had never prescribed. The experiences of these nurses, through identification of commonalities and exceptions to the norm, offer valuable insight into why nurse prescribing succeeds or fails.
Two prescribers in an outpatient unit described using clinical management plans – which detail circumstances when the supplementary prescriber can prescribe specific drugs for that patient and are agreed and signed in advance by the independent and supplementary prescribers as well as the patient—as initially time consuming, but successful in improving efficiency, prescribing practices and a robust framework for the ongoing review of each patient’s management.
Both described how practice improved through prescribing as a team:
1: We have subsequently introduced a new haemodialysis chart…
…are now actually legally prescribed and signed for and checked, so we’ve hopefully improved on practice and the safety of it…
…every three months we review those now on behalf of Dr Y, as she doesn’t have time to work through them and then the following month she will do it and therefore audit ours and will also see the patient in the clinic every three months, so she can review our decisions.
There was also a belief that patients benefit from the efficiency and responsiveness of the service, particularly as it now enables rapid management of common problems:
4: It has improved the speed at which the patients get their antibiotics for [IV] line infections.
Success was evidenced by the number of patients agreeing to have a clinical management plan for supplementary prescribing and general levels of patient satisfaction with the new procedures:
1: [I] have got experience of around a hundred and fifty… No-one has ever declined either [name of colleague] or myself, in fact, they would like us to do a lot more than we can.
There was concern that some patients may not give full consideration to what that consent means, but it was felt that the high level of trust between patient and professional that develops in long term care may account for this phenomenon.
Another issue that stems from this relationship is the pressure exerted on nurses to prescribe regular outpatient medications. Respondents stated firmly their commitment to only prescribing in their field of competence and were keen to ensure that their patients understood this.
There was support for the continuing development of nurse prescribing to meet patient need, but it was recognised that this must not be at the expense of other aspects of care or to compensate for gaps in service delivery created by shortfalls in medical cover.
The increase in responsibility was reported to be significant in relation to both prescribing and advising. Respondents described how confidence develops gradually but that prescribing something new can still be challenging. There was however evidence of support for newly qualified prescribers, from wider prescribing teams and improved interdisciplinary relationships.
The introduction of full independent prescribing from the British National Formulary (BNF) was welcomed as it was felt to have the potential to further improve efficiency and accountability.
Only one of the respondents was regularly prescribing independently at the time of the study and was able to prescribe a range of medication from the Nurse Prescribers’ Formulary (NPF) for both outpatients and inpatients. She described how nurse prescribing has improved care by increasing efficiency and effectiveness:
3: So I can see the patient, take the history, do the treatment and do the prescription.
Unfortunately, there was some frustration at the limitations of the NPF which at this time, included a number of condition-specific restrictions, leading to reliance on Patient Group Directions (PGDs) to cover the shortfall:
3: … you can give Metronidazole for a bladder infection, I can do that, thank you from my formulary, I get an ear swab back, sensitive to Metronidazole, I am very sorry, no you can’t, because it’s an ear.
The ability to write a prescription was welcomed as it introduces a safety check in the process (the pharmacist) and renders obsolete the PGD process, where an individual diagnoses, makes a treatment choice and then provides a supply of pre-packed drugs.
There was evidence that, once qualified as a nurse prescriber, staff sometimes felt under pressure to prescribe, even when the required prescription did not fall within their recognised remit. Respondents reported having to make clear to colleagues that they were only prepared to work within their own caseload and level of competence.
Barriers to prescribing
For some respondents, being unable to prescribe has been a source of frustration. Those with roles in chronic disease management saw patients either in an outpatient or community setting or during a one-off inpatient review. For those prescribing for chronic illness in a secondary care outpatient setting, the NPFs limited range prevented them prescribing for these conditions. Reducing prescribing costs in secondary care meant that only onsite treatment and emergency medication are financed and all other prescribing has to go through primary care via the General Practitioner as illustrated below:
5: We have these letters that we send out for non-urgent prescribing which of course when you are in outpatients 99·9% is non-urgent prescribing and you say to the GP, ‘I would like you to commence this patient on so and so, or change this medication to that medication’ or what have you. So, as such that is not a prescribing act, therefore we do not require supplementary clinical management plans, so that throws that, sort of, potential prescribing experience out the window.
Although inpatient care is not affected by such issues, a number of other barriers to prescribing were described. These included the transient, often ‘one-off’ nature of in-patient consultation/opinion seeking and the limitations of the NPF.
All participants looked forward to having access to the BNF, although there was a belief that it would not come without restrictions, particularly around opioids. Despite some respondents being unable to prescribe directly for their patients, they reported great hopes for the future of nurse prescribing and felt that skills learnt were being utilised in day to day practice when making recommendations to GPs or using PGDs:
2: I am forever increasing, decreasing, stopping, asking GPs to initiate medication, so sometimes it’s GPs that are actually asking advice on what that medication should be, what the dose should be and how frequent it should be, so in many senses I do prescribe with the backing of patient group directives and protocols.
There was acknowledgement that the problems encountered in implementing nurse prescribing in secondary care are not just isolated local issues but are being experienced nationally.
The issue of patient safety was of great concern to all participants. There was a very strong commitment to only ever prescribing within boundaries of competence and taking accountability for prescribing decisions. Some respondents believed nurse prescribers need to prove themselves whilst others were concerned that ‘rogue’ nurses would let the profession down by stepping outside the boundaries of their competence either due to being pressured to prescribe and having insufficient experience or authority to refuse, or not recognising boundaries of competence due to deficits in knowledge.
There was great emphasis on the need for appropriate post-registration experience before undertaking prescribing training, as it was believed that it is only through understanding the complexity of patients’ health state and their medical management, that prescribers could act safely. The use of electronic prescribing support for reducing the risk of error and improving communication was viewed positively.
Political issues in prescribing
Nurse prescribing was discussed in the context of current or future shortages of doctors and changes to the NHS skill mix (DH 2004). Participants believed that patient benefit rather than doctor shortage should be the motivation behind nurses prescribing.
There were a number of references to the power held by the medical profession, their ‘ownership’ of patients and the belief that nurse prescribers need to be adequately skilled, experienced and of strong character. However, prescribers reported being well-supported on the whole by members of the prescribing team and on two occasions the benefits of non-medical prescribing for professions allied to medicine was mentioned.
Concerns about nurse prescribing
There was a strong feeling that service development must take into account the additional work entailed in prescribing. There was also concern about nurse prescribing potentially becoming an element of pre-registration nurse education in the future. The belief that budgetary constraints would continue to impact negatively in terms of prescribing itself, numbers accessing training and the ability to demonstrate the effectiveness of nurse prescribers was shared by several respondents.
Benefits of nurse prescribing
The benefits of nurse prescribing have already been clearly illustrated by the accounts of participants who believed the longer term relationships established between the prescriber and the chronic disease patient promoted more effective prescribing and disease management partnerships.
Increased accountability was seen as a benefit in terms of safeguarding patients through better documentation and audit trail. Becoming a prescriber was generally described as a positive experience, even by those not currently prescribing. There was an awareness of increased responsibility but this was welcomed and respondents were prepared for this.
Although the initial uptake of nurse prescribing in secondary care appears to have been influenced by the government’s commitment to fund early cohorts, nurses themselves firmly believe it offers significant benefits in terms of patient care. Regrettably, hasty implementation did not allow for careful process or outcome evaluation and has led to some nurses being prevented from prescribing, mainly as a result of the way budgets for different drugs are managed between acute and primary care NHS trusts.
To date, reports on implementation in secondary care appear to be confined mainly to descriptive accounts (Gerrish 2004, Hennell et al. 2005, James 2005, Lilley et al. 2005, Wilkinson 2005, Astles 2006, Harniman 2006, Hacking & Taylor 2010), suggesting formal evaluation is a clear priority for employers and educators seeking to ensure effective deployment of nurse prescribing in this setting.
As noted by other researchers, participants in this study felt the pharmacological education was insufficient (Bradley & Nolan 2007, Courtenay & Carey 2007); however, none of the respondents reported this actually being an issue in practice. All spoke about knowing their limitations and when to seek advice or training; working within the scope of their competence was seen as an intrinsic part of being a nurse which is also consistent with published research (Harris et al. 2004, Hacking & Taylor 2010).
The pace of change in non-medical prescribing presents educators with new challenges as professionals from a broad range of disciplines seek competence to prescribe in their specialist fields. In this respect, the generic approach to prescribing education can be argued to be the only way forward (Courtenay 2005, Hemingway & Davies 2005, Travers 2005). However, in taking into account criticisms of being too primary care focused and not providing enough in-depth pharmacology, educators must review how they can meet the needs of the majority (Hemmingway & Davies 2005). One suggestion has been to harness the skills of the students themselves. Understanding students’ skills, perceptions and expectations at point of access, would enable misconceptions and problems relating to how the course is presented, to be addressed.
Confidence was reported as increasing with practice but there was a very strong feeling that nurse prescribing was not a role for all nurses, particularly junior nurses, as it was believed that advanced clinical skills and knowledge were required to make prescribing decisions. Pressure to prescribe was experienced from both patients and staff, but as is noted in other work, is usually resolved by clarifying the roles and responsibilities of the prescriber (Fisher 2004, Lewis-Evans & Jester 2004, Bowden 2005, Stenner et al. 2009). Prescribers should be advised to consult their manager if pressure is persistent or widespread, in order that remedial action can be considered. Such issues strengthen the case for the provision of a robust infrastructure to support prescribers.
The respondents in this study reported being well supported by their mentors, however, this finding may reflect the relationship of respect that exists between senior nurses and consultant medical staff who have worked together for some time, rather than the norm. As the number of health professionals seeking prescribing education rises, there is a need to ensure that there are sufficient numbers of suitably qualified mentors. If consistent standards of mentorship are to be maintained, further work into selection, preparation and assessment of mentors is advocated.
Barriers to prescribing appeared to relate either to the restrictions of the NPF, which have since been lifted, or to financial control measures. The practice of making recommendations to the GP who then issues the prescription, continues to affect those working in this setting, whether nurse or consultant. This practice is a result of financial boundaries between trusts, but raises questions as to whether this promotes poor prescribing practice for both parties. There is a clear need for local drugs and therapeutics committees to consider the implications of this practice.
Review of contemporary literature identifies benefits to patients and practice (Hacking & Taylor 2010) which were also described by participants in this study. Examples include the ‘one stop’ diagnosis and treatment offered in outpatients and the use of the clinical management plan as the basis for development of team prescribing and audit review processes. Whilst supplementary prescribing amongst nurses has largely been superseded by independent prescribing, this will be an area of further development for other professional groups. Concerns expressed around whether patients understood the role of the supplementary prescriber and read the clinical management plan they sign may warrant further research.
Overall, participants saw nurse prescribing as a valuable addition to existing roles and expansion of prescribing rights was believed to be positive step that promotes greater accountability and patient safety. This increase in responsibility was not undertaken lightly but was welcomed, as long as it was for patient benefit and not just to fill gaps left by staffing shortfalls. Respondents suggested workforce planning and review needs to take into account the additional time required to make prescribing decisions, if other aspects of care are not to be compromised.
Relevance to clinical practice
This study used in-depth interviews to explore the experiences of six nurse prescribers in secondary care and the philosophical approach employed to improve objectivity precluded the guiding of participants in any way. All were very experienced specialist nurses who were supported by a consultant medical colleague in their specialist field and as such, their experiences may not represent that of those working in more general roles in hospitals. The finding were however, broadly consistent with the large body of research from primary care settings suggesting that this research does raise a number of key issues that are relevant to current practice.
First, revisiting, the entry criteria to ensure it is fit for purpose is vital. Clear guidance on what the course delivers and the level of knowledge and skills in clinical examination, diagnosis and relevant disease management required before accessing prescribing education has the potential to increase prescribing rates amongst those registering as prescribers on completion of this education.
Prescriber support is also a key issue and the importance of good mentorship should not be limited to the pre-registration phase. The support of the prescribing team, peers and pharmacists was valued highly and is vital to patient safety however, as professionals redefine their roles and boundaries it is imperative that research is commissioned to ensure good practice is promoted and problems addressed.
Continuing professional development and effective update are essential elements of prescriber support. Although prescribers accept individual responsibility for maintenance of competence, the provision of a more formal programme with a specified minimum level of commitment and clear routes for dissemination of information should be a priority for all employers.
Finally, for employers and educators alike, there is a clear need to evaluate non-medical prescribing thoroughly, in order that non-medical prescribing is employed effectively and safely for the benefits of the patient.
The authors would like to sincerely thank all the respondents who gave their time to take part in the study.
Thanks also to the United Lincolnshire Hospitals NHS Trust which supported the lead author in undertaking her Masters degree and the British Heart Foundation which provided funding for data collection and transcription costs.
Study design: JMcK, JS; data collection and analysis: JS, JMcK and manuscript preparation: JS, JMcK, RK.
Conflict of interest
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