The views of patients with diabetes about nurse prescribing

Authors


Molly Courtenay, Division of Health and Social Care, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey GU2 7TE, UK. E-mail: m.courtenay@surrey.ac.uk

Abstract

Diabet. Med. 27, 1049–1054 (2010)

Abstract

Aims  To explore the views of patients with diabetes about nurse prescribing and the perceived advantages and disadvantages.

Methods  Patients were recruited from the case-loads of seven nurse prescribers in six National Health Service sites in England. Sites reflected the key settings in which nurses typically prescribe for patients with diabetes within primary care. Forty-one interviews were undertaken by trained qualitative researchers. Interviews addressed opinions and experiences of nurse prescribing; audiotapes were transcribed, coded, and themes identified.

Results  Patients were confident in nurse prescribing. Distinctions were made between the role of the nurse and that of the doctor, and views varied with regard to the extent patients felt nurses should work autonomously. Confidence in nurse prescribing was inspired by nurses’ specialist knowledge and experience, a mutual trusting relationship, a thorough consultation, and experience of the benefits of nurse prescribing. Communication between nurses and doctors about patient care, awareness by nurses of their area of competence, training and experience, specialist diabetes knowledge and access to training updates were considered important for safe prescribing. Patterns of attendance had changed in some cases, with patients tending to see doctors less often. Access to medicines was improved for patients during non-routine/emergency situations.

Conclusions  Nurse prescribing is acceptable to patients and can increase the efficiency of diabetes service in primary care. Workforce planners need to include the services of nurse prescribers alongside those of doctors.

Introduction

Primary care teams provide routine care for about 75% of patients with diabetes. Approximately 80% of general practices have a nurse trained in diabetes, and practice nurses run one-third of primary care diabetes clinics [1]. The role of these nurses often encompasses medicines management. Enhancing the roles of healthcare workers is key to improving accessibility of heathcare [2], and in the UK expanding nurses’ roles to include prescribing is a key component of the government’s National Health Service (NHS) modernization strategy [3,4]. Over 18 000 nurses in the UK (out of a total of approximately 690 000 nurses) have independent prescribing rights, which are the most extended worldwide. One-third prescribe medicines for patients with diabetes [5,6]. Most (60%) are based in primary care and approximately 37% work in a general practice [5].

Predicted benefits of nurse prescribing, including improved and timely access to medicines, better use of health professionals’ skills, flexible working and improved team working, have been achieved [7–9]. In addition, patients say they are confident in the ability of nurses to prescribe [10] and like the continuity of care [11–15], comprehensive information [12–14,16–18] and holistic care [15,16,18] that these nurses provide.

According to healthcare personnel, the benefits of nurse prescribing specific to diabetes care include increased service efficiency, the promotion of self-care and increased safety [19]. This is important, since people with diabetes report insufficient access to services [1,20] and gaps in their knowledge and confidence in managing their condition [1]. However, patients’ opinions about the acceptability and impact of nurse prescribing in this area are unknown.

Patients and methods

This qualitative study used semi-structured interviews to explore the views of patients with diabetes under the care of a diabetes nurse prescriber. Five or more participants were recruited from the case-load of each of seven nurse prescribers in primary care sites across England. The interview schedule was informed by earlier work [5,21].

Recruitment

Nurses were recruited via a diabetes prescriber network and contacts made through previous work [5,21]. All sites reflected the key settings in which nurses typically prescribe for patients with diabetes within primary care (see Table 1). Diabetes specialist nurses and nurse consultants predominantly treated patients with poorly controlled diabetes and prescribed a narrow range of medicines, including insulin’s and oral hypoglycaemic agents. By contrast, nurses working in general practice looked after patients whose diabetes was more controlled and prescribed a broad range of medicines for diabetes and its related co-morbidities [19]. Nurses were located in Greater London, the Midlands, Berkshire or Lincolnshire. Each had been qualified as a prescriber for between 2 and 5 years, had specialist training in diabetes and used Nurse Independent Prescribing.

Table 1.   Nurse prescriber title and setting
Nurse numberTitleSetting
N1Specialist practice nurseGeneral practice
N2Specialist practice nurseGeneral practice
N3Nurse consultantCommunity clinic
N4Diabetes Specialist NurseCommunity clinic
N5Practice nurse prescriberGeneral practice
N6Nurse practitionerGeneral practice
N7Practice nurse prescriberGeneral practice

Nurses provided researchers with a list of numbers relating to current patients (who met the selection criteria), from which 10–15 patients were randomly selected to receive a letter inviting them to participate in the study. Selection criteria included patients aged 16 and above with Type 1 or Type 2 diabetes who had been prescribed medication by the nurse prescriber. Patients willing to participate sent their contact details to the researchers, who then invited them to take part in an audio-recorded interview.

Data collection

Interviews lasting 30–40 min were undertaken between January and June 2009. Individual consent was obtained before each interview. Patients were offered £10 towards expenses. Interviews were conducted by experienced qualitative researchers without a nursing background (K.S. and T.H.) in the NHS setting that patients usually attended.

Ethics

Ethical approval for the study was obtained from both University of Surrey and NHS ethics committees. Research and development approval was obtained for the study to go ahead in each Primary Care Trust.

Analysis

A thematic analysis was conducted on the data. Interviews were coded with the aid of computer software for qualitative analysis (ATLAS Ti). A framework was then developed to focus analysis on the research questions (awareness and opinions about nurse prescribing, advantages and disadvantages of nurse prescribing). Through a process of constant comparison, the meaning and relationship between codes were analysed in relation to the research questions in order to produce explanatory themes.

Reliability was enhanced by the independent assessment of a random selection of 10 interviews coded by the second researcher. A high degree of agreement was achieved, and minor differences in code titles were discussed and agreed between researchers.

Results

57% of patients contacted by invitation letter, volunteered to participate in the study. 41 patients were recruited (see Table 2).

Table 2.   Patient profile
 RangeMean
Age37–87 years67 years
SexNumberPercentage
Male2663.4%
Female1536.6%
EthnicityNumberPercentage
White British3483%
Other ethnicities717%
Time since diagnosisRangeAverage
 9 months to 39 years9 years 8 months
Diabetes classNumberPercentage
Type 2 diabetes3995%
Type 1 diabetes24.8%
Current treatmentNumberPercentage
Diet only24.9%
Oral medication1331.7%
Insulin or insulin plus oral medication2663.4%
Length of time with current diabetes nurseNumberPercentage
First visit24.9%
2–4 visits in under a year1434%
Multiple visits over 1–4 years717%
Multiple visits over 5–9 years1126.8%
Multiple visits over 10 years or more717%

Three sites recruited more than five patients; these were nurse 2 (n = 8), nurse 3 (n = 6) and nurse 7 (n = 7). Nurses 5 and 6 worked at the same practice and would both see the same patient at different times; therefore, patients are all recorded under ‘nurse 5’.

Five themes were identified. Quotations have been selected to illustrate themes and coded to protect anonymity as follows: GP, general practice setting; CC, community clinic setting; n, nurse number; and p, patient number.

Benefits of efficiency and access

Seeing the nurse was said to free more time for doctors and nurses, reduce waiting times and improve efficiency. Patients noted that patterns of attendance had changed. Some visited the doctor less often regarding diabetes, which was facilitated by the nurses’ ability to prescribe. Review appointments, which previously entailed visiting a nurse and doctor on the same visit, were replaced in some cases by alternate 6 monthly appointments with the nurse or doctor. Since the nurse could prescribe during routine appointments, patients no longer had to wait for the nurse to obtain a prescription from a doctor.

‘Usually I see the nurse, then I have to see the doctor. If the nurse can prescribe insulins and anything I need like that, then I think it’s going to cut a lot of time.’ (CC n3 p4)

Patients noted that it was easier and quicker to get a non-review appointment with the nurse prescriber, and access to medicines was improved during non-routine/emergency situations. Nurses were said to be more likely than doctors to be flexible and make time to see patients when required [15].

‘You can see the nurse a lot quicker than you can the doctor. You can virtually phone up in the morning. One particular day I felt really ill and NP said “Oh come straight down”. If that had been the doctor it is unlikely you would have seen the doctor that same day. But the nurse is always available. They always seem to be able to fit you in.’ (GP n6 p1)

An important contributor to improving access to advice and medications, reported by nurses working in general practice and community clinics, was the ability to contact the nurse prescriber by telephone. This provided a reassuring ‘safety net’ that helped patients through transition periods, such as learning a new treatment regime.

‘I couldn’t get through to the prescription line and she [nurse prescriber] had given me her mobile and said if you have any problems then ring, so I did. I said “I need some insulin and I can’t get through to the prescription line”. She wrote it there and then and I picked it up and it was done. It was great for me.’ (GP n5 p10)

In addition, patients were more willing to contact a nurse in this way because doctor’s time was perceived as more important and best reserved for ‘serious’ health issues. For this reason, some patients were more reluctant to contact doctors in the same way that they would a nurse.

‘Dr X is a general practitioner and although [NP5] is an incredibly busy person, Dr X is an incredibly busy person, they have got very different roles really. I accept that Dr X has very different responsibilities. I would never presume to ring Dr X up, whereas I feel quite comfortable ringing [NP5] up. If I was really desperate I would, but there are times when I can’t even get a normal appointment to see Dr X.’ (GP n5 p6)

Confidence in nurse prescribing

Patients were happy to be prescribed medication for diabetes by their nurse prescriber and in many cases preferred to see the nurse. Confidence in the nurses’ ability to prescribe stemmed from nurses’ specialist knowledge and regular experience in diabetes.

‘No, I’m quite happy. If they prescribe they know their job and they are seeing people with diabetes every day, so they know what to look for.’ (GP n5 p2)

A mutual trusting relationship also inspired confidence. Decisions made about healthcare were considered accurate and safe because the nurse knew and understood the patient’s medical background, records and history.

‘Well I’m 100% sure myself what ever decision she is making she is making the right decision for me because she knows my record, she knows the “ins and outs” of my medicine and any other report is in front of them. I’ve never had a problem.’ (GP n2 p2)

Direct experience of benefiting from nurses’ knowledge and advice also increased confidence. Some patients linked their confidence to examples where the nurse had solved health problems that doctors had missed.

‘The nurse already knew something was wrong but unfortunately the first doctor missed that. So I think the nurse in this surgery is quite good. I have confidence, yes.’ (GP n1 p3)

Good communication and interpersonal skills reported in nurses helped patients feel comfortable in asking questions and raising concerns. This interactive style made patients more confident about the suitability of treatment decisions. Patients also gained confidence from the nurses’ attention to detail during review appointments.

‘I think that is very important that they don’t skimp. When I come in she’ll take my weight, do my feet, do my blood pressure, want to know when I last had my eyes checked. A fortnight before I come in I have all the blood tests done, and we go through those, what’s wrong, what’s right and all this sort of thing and we just talk about it.’ (GP n2 p3)

Attitude towards safety was also described as important. If nurses were unsure about a treatment decision or there was a need for a change of medication, it was expected that the nurse would communicate with the doctor. Patients assumed a behind-the-scene flow of information between doctors and nurses (or between community clinic and general practice) about such things as test results and medication changes. Confidence was inspired when nurses demonstrated awareness of their own limitations and referred to doctors or other services. Where patients witnessed such communication it gave them increased confidence in the safety of the system.

‘As long as they can refer to a doctor if they are unsure themselves, as long as they can do that I’m quite happy.’ (GP n5 p2)

Disadvantages and conditions

The few disadvantages reported were about perceived limitations of nurses’ medical knowledge, training or ability to prescribe.

‘The disadvantages I can see, if there is some change in my condition, then the nurse really has to refer back to the doctor.’ (GP n1 p3)

Conditions which patients expected to be in place for a nurse to prescribe safely included necessary training and experience.

‘Well I think if you have had the education to prescribe there is no reason why a nurse shouldn’t do it.’ (CC n4 p3)

Specialist knowledge in diabetes was another requirement.

‘I can’t see any drawbacks, no. As long as I see a diabetic nurse, you know. Sometimes I do see a nurse who takes the blood sample, but she can’t—she’ll take the blood sample but she can’t do anything else.’ (CC n3 p4)

Continued training in diabetes and access to training updates were also considered important.

‘We belong to Diabetes UK and they run all these different courses, which we told the nurse prescriber about … she didn’t know about them, but we think that Diabetic Nurses should. I think the practice should pay for them to go on it.’ (GP n6 p1)

Role distinction between doctors and nurses

While patients were happy with the nurse prescriber, they saw the nurses’ role as distinct from that of the doctor, for example, most would ask for a doctor if they thought there was something wrong that was not related to diabetes. For some, the role of the general practice diabetes nurse was to monitor their condition and continue to prescribe medication initiated by the doctor. They did not expect the nurse to diagnose new conditions or prescribe new medication.

‘Because it’s not an illness where you are having to diagnose the illness, it is already there, so it’s monitoring and maintaining. A qualified nurse in that sphere is fine. I think that frees up the doctor. But where they do have to look for an illness, they have to diagnose an illness—I see a doctor doing that as opposed to a nurse. A practice nurse always works with patients, I would see, who have been diagnosed and it’s a maintaining programme—it is a matter of regular checkups, medication reviews and so on, and that’s a maintenance programme.’ (GP n5 p9)

In contrast, patients of specialist nurses in community clinics did expect the nurse to prescribe new medication or equipment, but only in relation to diabetes.

‘She’s prescribing diabetic drugs and if she is competent in that then that should be fine. I mean she’s not gonna prescribe heart attack tablets and that sort of thing. You know, that’s maybe when I might get a bit worried!’ (CC n3 p1)

While some patients were comfortable if the nurse was restricted to prescribing diabetic medication, others within general practice were happy to be prescribed medicines for co-morbidities and reported this to be helpful and time saving.

Discussion

This is the first study to explore the views of patients’ with diabetes about nurse prescribing and has important implications for service delivery.

Patients reported that nurse prescribing improved service efficiency and access to medicines. This finding supports previous research on nurse prescribing in general [22] and within diabetes care [19]. Importantly, participants explained how these improvements occurred, giving examples of requiring fewer appointments with doctors to obtain prescriptions, no longer waiting for the nurse to get a prescription signed by the doctor, and easier access to non-review appointments, supported by telephone advice. It therefore contributes to improving services in ways that are important to patients.

Nurse prescribing was welcomed by patients, and few disadvantages were reported other than potential limitations in nurses’ training. In line with the literature [19,20], patients emphasized the necessity for up-to-date knowledge of diabetes and treatment options. Nurses’ specialist knowledge and expertise inspired confidence in patients, as did a mutual trusting relationship, the quality of the consultation, regular contact and experiencing benefits. Interestingly, in other areas of practice [23], patients are reported to have greater confidence in general practitioners over nurses, for similar reasons (trusting relationship, rapport and doctor’s extensive knowledge). However, in contrast to our work, where most (over 40%) of patients had experienced ongoing consultations with the nurse over 5 years or longer, the research of Redsell et al. [23] compared patients’ accounts of consultations with nurses and doctors for emergency appointments, which were more likely to be one-off appointments. Therefore, perhaps ‘knowing’ the practitioner is of greater importance than the professional role of the practitioner for inspiring confidence and trust. This is important, because confidence is linked to the likelihood of taking medicines [10,24]. This requires further exploration.

In common with previous research [10,13,25], patients made distinctions between doctor and nurse prescribing roles, expecting continued doctor involvement and preferring to see the doctor for what they considered serious or undiagnosed health issues. Teamwork between healthcare professionals has been described as an integral aspect of nurse prescribing practice in diabetes care [19]. This study confirms that patients expected continued teamwork and considered it essential to safe care for patients with diabetes; a sentiment that is backed by national guidance [26,27]. However, patients’ views varied with regards to the autonomy they thought nurses should have when prescribing. Some saw the role of the general practice nurse as restricted to monitoring and prescribing medicines initiated by the doctor. By contrast, patients of specialist nurses were happy for the nurse to prescribe new diabetic medicines, and other patients of general practice nurses were happy for nurses to prescribe medicines for co-morbidities. Patients’ expectations of nurse prescribing are likely to differ according to experience of different nursing roles. Given the specialist role of diabetes specialist nurses, it is perhaps unsurprising that patients of these nurses were happy for them to prescribe new medicines. The varied views of patients of general practice nurses is more surprising and perhaps reflects differences in scope of practice and levels of autonomy reported by these nurses in diabetes services [28].

Our work could have been strengthened if more nurses working in community clinics had been recruited. In addition, nurses may have volunteered because of their high level of competence and experience in diabetes; therefore, findings may not represent the experiences of all patients with diabetes. However, nurses selected do reflect the key settings in which nurses typically prescribe for patients with diabetes within primary care.

Despite these limitations, our findings that nurse prescribing is acceptable to patients on condition that nurses are appropriately trained, work within their competence and continue to work alongside other healthcare professionals, mirrors the views of other health professionals within diabetes services [19]. If the level of autonomy that patients are happy with is related to their experiences, patient views and expectations may change as more nurses adopt prescribing. Our work adds to the literature on service efficiency and demonstrates specifically how nurse prescribing can increase the efficiency of diabetes services in primary care. Given the concerns over the services that patients with diabetes receive [1,20], this should be borne in mind by workforce planners. Additionally, given the increasing demands on diabetes services worldwide, those countries developing non-medical prescribing policy need to bear in mind the contribution that nurse prescribers can make to diabetes service delivery. Further research is required to examine the effects of nurse prescribing on medicines concordance.

Competing Interests

Nothing to declare.

Acknowledgements

This work was funded by an unrestricted research grant from Sanofi-Aventis. We thank Jill Hill, Nurse Consultant, for her assistance with regards to the recruitment of participants and Tanya Hector for her help with data collection.

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