Nurse-patient relationships: the context of nurse prescribing

The role of nurse-client relationships in maternal and child healthcare: a qualitative study in rural Tanzania

Background

The literature suggests that poor provider-client relationships in maternal and child healthcare (MCH) continue to impact healthcare service uptake, continuity of care, and MCH outcomes. However, there is a paucity of literature on the benefits of the nurse-client relationship for clients, nurses, and the health system, particularly in rural African contexts.

Objective

This study examined the perceived benefits and disadvantages of good and poor nurse-client relationships in rural Tanzania respectively. We present the findings of a community-driven inquiry that was the first step of a broader study that sought to co-design an intervention package for strengthening nurse-client relationships in MCH in rural contexts using a human-centred design approach.

Methods

This study used a qualitative descriptive design. Nine focus group discussions and 12 key informant interviews were conducted using semi-structured interview guides. Participants were purposefully selected nurses/midwives and clients attending MCH services, and MCH administrators. Data were managed using NVivo and analysed thematically.

Results

A range of perceived benefits of good nurse-client relationships and disadvantages of poor relationships emerged. Perceived benefits of good nurse-client relationships included: (i) benefits to clients (increased healthcare-seeking behaviours, disclosure, adherence, return to care, positive health outcomes, and referral tendencies); (ii) benefits to nurses (increased confidence, efficiency, productivity, job satisfaction, trust, and community reputation and support); and (iii) benefits to healthcare facilities/systems (increased client load and consequently income, fewer complaints and legal disputes, increased trust and facility delivery, and reduced maternal and child deaths). The disadvantages of poor nurse-client relationships were basically the opposite of their benefits.

Conclusion

The benefits of good nurse-client relationships and the disadvantages of poor relationships extend beyond patients and nurses to the healthcare system/facility level. Therefore, identifying and implementing feasible and acceptable interventions for nurses and clients could pave the way for good nurse-client relationships, leading to improved MCH outcomes and performance indicators.

Patient view of the advanced practitioner (AP) role in primary care: A realist-informed synthesis

BACKGROUND

Approximately 30% of general practitioner consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat a range of MSKDs, and could provide the first point of contact for primary care patients. There is limited evidence on whether this role is acceptable to patients; however, previous research has explored advanced practitioner (AP) roles in primary care, which could inform this new initiative.

AIMS

This study used realist synthesis to explore factors that influence patient acceptability of AP roles in primary care. MATERIALS & METHODS: A realist synthesis was undertaken to identify initial programme theories regarding acceptability. Databases were searched to identify relevant literature. Identified studies were subject to inclusion and exclusion criteria, resulting in 38 studies included for synthesis. Theory-specific data extraction sheets were created and utilised. Data were analysed through identifying contexts, mechanisms and outcomes to formulate hypotheses. Hypotheses were validated through consultation with expert stakeholders.

RESULTS

Eight theory areas were identified that potentially impacted on patient acceptability of the role: patient's prior experience of condition management; patient's expectations of condition management; communication; continuity of the individual practitioner; practitioner's scope of practice; accessibility; professional hierarchy and promoting the role. Nineteen hypotheses on the AP role were developed around these theory areas.

DISCUSSION

Role acceptabiliy was influenced significantly by context and may change as the role develops, for instance, as waiting times change.

CONCLUSION

Hypotheses will inform a subsequent realist evaluation exploring the physiotherapy AP role in primary care. Future research is needed to understand the acceptability of first contact physiotherapists delivering certain skills.

Effect of counseling on maternal-fetal attachment in women with unplanned pregnancy: a randomized controlled trial

Introduction: Since the maternal-fetal attachment level in unplanned pregnancies is weaker than their planned counterparts, this study aimed to determine the effect of counselling on maternal-fetal attachment in women with unplanned pregnancy.Methods: This was a randomised controlled clinical trial on pregnant women with unplanned pregnancy and weak-average maternal-fetal attachment scores. Participants were assigned to a control (n = 40) and an intervention (n = 40) group through randomised blocking. The intervention group attended 1-3 individual and 6 group counselling sessions and the control group received routine care. The participants completed the Maternal-Fetal Attachment Scale before and four weeks after the intervention.Results: The mean (standard deviation) maternal-fetal attachment score of the intervention group was increased from 73.6 (8.9) before the intervention to 96.6 (9.3) after the intervention. However, the mean (standard deviation) maternal-fetal attachment scores of the control group were 76.0 (9.4) and 76.5 (6.4) before and after the intervention, respectively. The mean maternal-fetal attachment score of the counselling group was significantly higher than that of the control group (adjusted mean difference: 21.7; 95% confidence interval: 18.6 to 24.9; P < 0.001).Conclusion: Counseling has a positive contribution to improving maternal-fetal attachment in women with unplanned pregnancies.

Psychiatrists' and nurses' views of mental health nurse supplementary prescribing: a survey

Aims and Method

A questionnaire survey of psychiatrists and mental health nurses was conducted to look at their awareness of nurse supplementary prescribing and its impact on patient care.

Results

Response rate was 49.5% for psychiatrists and 23% for nurses. Most nurses (96.2%) and psychiatrists (91%) were aware of nurse supplementary prescribing, but more nurses than psychiatrists felt that it will provide patients quicker access to medication (P=0.023) and improve patient care (P=0.0003). Although two-thirds of the nurses felt confident to be a nurse prescriber, only 13% had actually approached a psychiatrist to be their supervisor. Most psychiatrists (54.4%) did not feel confident to act as supervisors.

Clinical Implications

Unlike nurses, psychiatrists were cautious about potential benefits of nurse supplementary prescribing on patient care. Both nurses and psychiatrists expressed concerns. As the expansion of nurse prescribing occurs, it is important for trusts to work actively with nurses and psychiatrists to address these concerns.

Mental health nurse supplementary prescribing: mapping progress 1 year after implementation

Aims and Method

A postal questionnaire survey was conducted of the directors of nursing of all mental health NHS trusts in England, in order to examine current activities and attitudes regarding nurse supplementary prescribing (NSP) in psychiatric settings.

Results

Fifty-four per cent of nurse directors returned the questionnaire. They perceived that NSP was an important means for improving patient care and treatment, particularly in community settings. In their opinion, psychiatrists were generally not opposed to its introduction. To date, relatively few mental health nurses have received training in NSP.

Clinical Implications

Directors of nursing have positive views and experiences of NSP. Widespread implementation of NSP is likely to occur over the next few years and psychiatrists will need to consider how this will impact on their role.

Mental health nurse prescribing: The research challenge

Nurse prescribing is gradually being implemented across a range of areas in healthcare. This paper examines the context of prescribing for mental health problems and discusses the issues relating to nursing and some of the broader matters such as the effectiveness of medication for mental health problems, the economics of mental illness and more general workforce issues. Mental health nurse prescribing obviously presents some significant research opportunities that should be seen within the settings of the Medical Research Council's framework for assessing complex health interventions (Campbell et al., 2000). The paper also considers some of the challenges of undertaking a randomised controlled trial for a topic within what Nancy Woolf (2000) describes as a 'socially complex service context'. Such a context requires the research team to consider a number of potential confounds. The paper concludes by suggesting some ways that such sources of confound be minimised.

Evaluating prescribing competencies and standards used in nurse independent prescribers’ prescribing consultations

Background Independent prescribing of medicines by nurses is widely considered to be part of advanced nursing practice, and occurs within an episode of patient care that can be completed independently by a nurse. Nurse prescribers therefore require the competencies necessary to manage a consultation—such as history taking and diagnostic skills—and subsequently need to decide on any appropriate medicine to be prescribed. Safe prescribing should also involve an accurate, legible and comprehensive written prescription and documentation of the consultation in the patient’s records. However, the extent to which nurse independent prescribers use prescribing competencies and standards in practice had not been researched prior to this study.

Aim To describe the frequency with which nurses use a range of prescribing competencies in their prescribing consultations, in order to provide a measure of the quality and safety of nurses’ independent prescribing practices.

Design and methods Across 10 case study sites, 118 nurse independent prescribers’ prescribing consultations were analysed using non-participant observation and a structured checklist of prescribing competencies. Documentary analysis was also undertaken of a) prescriptions written ( n =132) by nurses and b) the record of the prescribing episode in patient records ( n =118).

Sample and setting 118 prescribing consultations of 14 purposively selected nurse independent prescribers working in primary and secondary care trust case study sites in England.

Findings Nurse independent prescribers were issuing a prescription every 2.82 consultations; nurses used a range of assessment and diagnosis competencies in prescribing consultations, but some were employed more consistently than others; nurses almost universally wrote full and accurate prescription scripts for their patients; nurses recorded each of their prescribing consultations, but some details of the consultation and the prescription issued were not always consistently recorded in the patient records.

Conclusion The findings from this observation study provide evidence about the quality and safety of nurses’ prescribing consultations in England.

National survey of nurse prescribing in mental health services; a follow-up 6 years on

WHAT IS KNOWN ON THE SUBJECT?: Nurse prescribing allows nurses, after specific training, to prescribe medications under certain conditions. This article describes the third in a series of surveys of mental health services in England to understand how nurse prescribing is being used across the country. While there is research evidence that shows nurse prescribing to be as safe as prescribing by doctors and that service users typically find it at least as acceptable, there is a lack of detailed evidence about current forms of nurse prescribing practice specifically in mental health services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The survey found that the number of nurse prescribers has increased over the last few years. Nurse prescribers are increasingly prescribing in a form ('independent prescribing') that makes them independently responsible for prescribing decisions without working to a plan laid out by a doctor. Mental health organisations are increasingly planning in a systematic way how to identify, train and ensure good practice in nurse prescribing. This study demonstrates that growth in numbers of nurse prescribers can take place over an extended time period. The study demonstrates that the exact model of nurse prescribing will influence its applicability in different types of service. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse prescribing is becoming increasingly common in mental health services, changing roles for nurses and the experience of services for service users. However, there is great variation between organisations in this regard. Research is needed regarding the outcomes and any risks of independent nurse prescribing specifically in mental health compared to medical prescribing.

ABSTRACT

Introduction This paper reports the latest in a series of national surveys of nurse prescribing in mental health organizations in England. Aim To describe and understand changes and trends in the use of nurse prescribing nationally. Methods Postal survey to all 53 National Health Service Mental Health Trusts (publicly funded provider organizations); 75% responded (n = 40). Results Numbers of nurse prescribers (NPs) have grown significantly in the last 6 years, although remain a small percentage of the total Mental Health Nursing workforce. Most NPs are in community services, particularly community mental health teams and drug/alcohol services. Independent prescribing has now become the most common form of NP, replacing supplementary prescribing. Discussion Overall growth in numbers of NPs has continued, but remains marked by large variance in numbers between organizations. The study evidences that the particular form of nurse prescribing will influence its applicability in different clinical settings and that sustained increase over time in NP numbers is feasible at a national level, even with local variation in uptake. Implications for practice Nurse prescribing has become well embedded in many organizations although large-scale adoption may be hindered by the lack of a definitive evidence base as to outcomes compared with those from medical prescribing.

Measuring patient satisfaction in complex continuing care/rehabilitation care

Purpose

To develop a psychometrically validated survey to assess satisfaction in complex continuing care/rehabilitation patients.

Design/methodology/approach

A paper or computer-based survey was administered to 252 complex continuing care/ rehabilitation patients (i.e., post-acute hospital care setting for people who require ongoing care before returning home) across two hospitals in Toronto, Ontario, Canada.

Findings

Using factor analysis, five domains were identified with loadings above 0.4 for all but one item. Behavioral intention and information/communication showed the lowest patient satisfaction, while patient centredness the highest. Each domain correlated positively and significantly predicted overall satisfaction, with quality and safety showing the strongest predictive power and the healing environment the weakest. Gender made a significant contribution to predicting overall satisfaction, but age did not.

Research limitations/implications

Results provide evidence of the survey’s psychometric properties. Owing to a small sample, supplemental testing with a larger patient-group is required to confirm the five-factor structure and to assess test-retest reliability.

Originality/value

Improving the health system requires integrating patient perspectives. The patient experience, however, will vary depending on the population being served. This is the first psychometrically validated survey specific to a smaller speciality patient group receiving care at a complex continuing care/rehabilitation facility in Canada.

Patients' valuation of the prescribing nurse in primary care: a discrete choice experiment

BACKGROUND

Recently, primary care in the United Kingdom has undergone substantial changes in skill mix. Non-medical prescribing was introduced to improve patient access to medicines, make better use of different health practitioners' skills and increase patient choice. There is little evidence about value-based patient preferences for 'prescribing nurse' in a general practice setting.

OBJECTIVE

To quantify value-based patient preferences for the profession of prescriber and other factors that influence choice of consultation for managing a minor illness.

DESIGN

Discrete choice experiment patient survey.

SETTING AND PARTICIPANTS

Five general practices in England with non-medical prescribing services, questionnaires completed by 451 patients.

MAIN OUTCOME MEASURE

Stated choice of consultation.

MAIN RESULTS

There was a strong general preference for consulting 'own doctor' for minor illness. However, a consultation with a nurse prescriber with positive patient-focused attributes can be more acceptable to patients than a consultation provided by a doctor. Attributes 'professional's attention to Patients' views' and extent of 'help offered' were pivotal. Past experience influenced preference.

DISCUSSION AND CONCLUSION

Respondents demonstrated valid preferences. Preferences for consulting a doctor remained strong, but many were happy to consult with a nurse if other aspects of the consultation were improved. Findings show who to consult is not the only valued factor in choice of consultation for minor illness. The 'prescribing nurse' role has potential to offer consultation styles that patients value. Within the study's limitations, these findings can inform delivery of primary care to enhance patient experience and substitute appropriate nurse prescribing consultations for medical prescribing consultations.

Solicitations in GP, nurse and pharmacist prescriber consultations: an observational study

BACKGROUND

The opening solicitation is a key element of the primary care consultation as it enables patients to express their ideas, concerns and expectations that can lead to improved patient outcomes. However, in practice, this may not always occur. With nurses and pharmacists now able to prescribe, this research explored the opening solicitation in a multi-professional context.

OBJECTIVE

To compare the nature, frequency and response to opening solicitations used in consultations with nurse prescribers (NPs), pharmacist prescribers (PPs) and GPs.

METHODS

An observational study using audio-recordings of NP, PP and GP patient consultations in 36 primary care practices in southern England. Between 7-13 prescriber-patient consultations were recorded per prescriber. A standardized pro forma based upon previous research was used to assess recordings.

RESULTS

Five hundred and thirty-three patient consultations (213 GPs, 209 NPs, 111 PPs) were audio-recorded with 51 prescribers. Across the prescribing groups, pharmacists asked fewer opening solicitations, while GPs used more open questions than NPs and PPs. The mean number of patient agenda items was 1.3 with more items in GP consultations. Patients completed their opening agenda in 20% of consultations, which was unaffected by professional seen. Redirection of the patient's agenda occurred at 24 seconds (mean).

CONCLUSION

All prescribers should be encouraged to use more open questions and ask multiple solicitations throughout the consultation. This is likely to result in greater expression of patients' concerns and improved patient outcomes.

A comparison of GP, pharmacist and nurse prescriber responses to patients' emotional cues and concerns in primary care consultations

OBJECTIVE

Recognising patients' cues and concerns is an important part of patient centred care. With nurses and pharmacists now able to prescribe in the UK, this study compared the frequency, nature, and professionals' responses to patient cues and concerns in consultations with GPs, nurse prescribers and pharmacist prescribers.

METHODS

Audio-recording and analysis of primary care consultations in England between patients and nurse prescribers, pharmacist prescribers and GPs. Recordings were coded for the number of cues and concerns raised, cue or concern type and whether responded to positively or missed.

RESULTS

A total of 528 consultations were audio-recorded with 51 professionals: 20 GPs, 19 nurse prescribers and 12 pharmacist prescribers. Overall there were 3.5 cues or concerns per consultation, with no difference between prescriber groups. Pharmacist prescribers responded positively to 81% of patient's cues and concerns with nurse prescribers responding positively to 72% and GPs 53% (PhP v NP: U = 7453, z = -2.1, p = 0.04; PhP v GP: U = 5463, z = -5.9, p < 0.0001; NP v GP: U = 12,070, z = -4.9, p < 0.0001).

CONCLUSION

This evidence suggests that pharmacists and nurses are responding supportively to patients' cues and concerns.

PRACTICE IMPLICATIONS

The findings support the importance of patient-centredness in training new prescribers and their potential in providing public health roles.

A patient perspective of pharmacist prescribing: 'crossing the specialisms-crossing the illnesses'

BACKGROUND

The drive for non-medical prescribing has progressed quickly since the late 1990s and involves a range of healthcare professionals including pharmacists. As part of a commissioned research project, this qualitative element of a larger case study focused on the views of patients of pharmacist prescribers.

OBJECTIVE

The aim of this study was to explore patients' perspectives of pharmacists as prescribers.

METHODS

Three pharmacists working as independent prescribers in the clinical areas of (i) hypertension, (ii) cardiovascular/diabetes management, (iii) anticoagulation were recruited to three case studies of pharmacist prescribing in Northern Ireland. One hundred and five patients were invited to participate in focus groups after they had been prescribed for by the pharmacist. Focus groups took place between November 2010 and March 2011 (ethical/governance approvals granted) were audio taped, transcribed verbatim, read independently by two authors and analysed using constant comparative analysis.

RESULTS

Thirty-four patients agreed to participate across seven focus groups. Analysis revealed the emergence of one overarching theme: team approach to patient care. A number of subthemes related to the role of the pharmacist, the role of the doctor and patient benefits. There was an overwhelming lack of awareness of pharmacist prescribing. Patients discussed the importance of a multidisciplinary approach to their care and recognized limitations of the current model of prescribing.

CONCLUSION

Patients were positive about pharmacist prescribing and felt that a team approach to their care was the ideal model especially when treating those with more complex conditions. Despite positive attitudes, there was a general lack of awareness of this new mode of practice.

Assessing the contribution of prescribing in primary care by nurses and professionals allied to medicine: a systematic review of literature

Background

Safe and timely access to effective and appropriate medication through primary care settings is a major concern for all countries addressing both acute and chronic disease burdens. Legislation for nurses and other professionals allied to medicine to prescribe exists in a minority of countries, with more considering introducing legislation. Although there is variation in the range of medicines permitted to be prescribed, questions remain as to the contribution prescribing by nurses and professionals allied to medicine makes to the care of patients in primary care and what is the evidence on which clinicians, commissioners of services and policy makers can consider this innovation.

Methods

A integrative review of literature on non-medical prescribing in primary care was undertaken guided by dimensions of health care quality: effectiveness, acceptability, efficiency and access.

Results

19 papers of 17 empirical studies were identified which provided evidence of patient outcome of non medical prescribing in primary care settings. The majority were undertaken in the UK with only one each from the USA, Canada, Botswana and Zimbabwe. Only two studies investigated clinical outcomes of non-medical prescribing. Seven papers reported on qualitative designs and four of these had fewer than ten participants. Most studies reported that non medical prescribing was widely accepted and viewed positively by patients and professionals.

Conclusions

Primary health care is the setting where timely access to safe and appropriate medicines is most critical for the well-being of any population. The gradual growth over time of legislative authority and in the numbers of non-medical prescribers, particularly nurses, in some countries suggests that the acceptability of non-medical prescribing is based on the perceived value to the health care system as a whole. Our review suggests that there are substantial gaps in the knowledge base to help evidence based policy making in this arena. We suggest that future studies of non-medical prescribing in primary care focus on the broad range of patient and health service outcomes and include economic dimensions.

The impact of nurse prescribing on patients with osteoarthritis

Osteoarthritis (OA) is now considered one of the ten most disabling diseases in developed countries and it is estimated that worldwide, 18% of women and 9.6% of men aged over 60, suffer from OA. It is, therefore, vital to take into consideration the demographics of this disorder, including the health needs of this age group and associated problems, such as reduced mobility or immobility and the inability to perform everyday tasks associated with chronic pain. Older patients, however, are sometimes able to accept their condition and adopt a positive outlook towards their OA as a coping strategy. This association with and acceptance of pain by the patient as a normal part of the ageing process may compromise the patient's ability to undertake activities of daily living and impact their psychological wellbeing.

The views of patients with diabetes about nurse prescribing

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.

Nurse prescribing in mental health: national survey

Mental health nurses can now train to become independent prescribers as well as supplementary prescribers. Independent nurse prescribing can potentially help to reorganize mental health services, increase access to medicines and improve service user information, satisfaction and concordance. However, mental health nursing has been slow to undertake prescribing roles, and there has been little work conducted to look at where nurse prescribing is proving successful, and those areas where it is less so. This survey was designed to collect information from directors of nursing in mental health trusts about the numbers of mental health prescribers in England, gather views about prescribing in practice, and elicit intentions with regards to the development of nurse prescribing. In some Trusts, the number of mental health nurse prescribers has increased to the point where wider impacts on workforce, the configuration of teams and services are inevitable. Currently, the way that prescribing is used within different organizations, services and teams varies and it is unclear which setting is most appropriate for the different modes of prescribing. Future work should focus on the impact of mental health nurse prescribing on service delivery, as well as on service users, colleagues and nurses themselves.

Survey of psychiatrists' views of nurse prescribing

For mental health nurses and service users to realize the benefits of non-medical prescribing, psychiatrists need to understand the remit of this role and be actively involved in influencing it. Although healthcare policy in the UK supports the expansion of non-medical prescribing, it requires much more for the successful implementation of such initiatives in practice. The aim of this survey was to explore the attitudes of all grades of psychiatrist working in two mental health trusts in the West Midlands to nurse prescribing. A specifically designed questionnaire was sent out to two groups of psychiatrists to assess their attitudes towards non-medical prescribing. Psychiatrists (n = 147) completed and returned a specifically designed questionnaire of their views. The more senior doctors appeared less concerned about nurse prescribing. Junior doctors expressed equivocation towards the role, suggesting that nurse prescribers be consistently supervised and have limited access to mental health drugs. The findings from this study have considerable implications for teams if junior doctors hold different views to their senior colleagues. Without the assistance of trusts in facilitating role change, the introduction of new roles could potentially heighten conflict between professions.

Nurse prescribing, policy, practice and evidence base

There are now over 30,000 nurses across the UK who are qualified to prescribe from the Nurse Prescribing Formulary (NPF) for community practitioners. Training to prescribe from this formulary is now available to community staff nurses. Increasing numbers of community nurses are extending their prescribing skills by adopting independent and supplementary prescribing. Over 14,000 nurses across the UK are qualified to prescribe using these modes of prescribing. The benefits of nurse prescribing exceed those anticipated by the Government. However, there is some misunderstanding by doctors about the prescribing role. Doctors have concerns about nurses encroaching on medical territory, nurses' clinical skill base, and the possibility that nurses will prescribe outside of their area of competence. If doctors have an established relationship with a nurse prior to the adoption of prescribing, and have experienced some of the tangible benefits of this role, this helps to readdress these concerns. The increasing numbers of community nurses adopting and extending their role in the prescription of medicines is an indication that healthcare reforms, shifting care into the community, means that nurses are frequently the first point of contact from whom patients access their medicines. If the benefits of nurse prescribing are to be maximized and nurses are to feel supported in this role, there is a need to educate doctors about the professional limitations of nurse prescribing.

The use of cognitive continuum theory and patient scenarios to explore nurse prescribers’ pharmacological knowledge and decision-making

BACKGROUND

Nurses have been involved in prescribing in England since 1996, and to date over 41,000 nurses are registered with the Nursing and Midwifery Council as prescribers. The majority of evaluative research on nurse prescribing is descriptive and relies on self-report and assessment of patient satisfaction.

OBJECTIVES

To explore and test nurse prescribers' pharmacological knowledge and decision-making.

DESIGN

An exploratory approach to test the usefulness of patient scenarios in addressing the reasons why nurses decide whether or not to prescribe was utilised. Semi-structured interviews with nurse prescribers using patient scenarios were used as proxy methods of assessment of how nurses made their prescribing decisions.

SETTING

Two primary care trusts in the southeast of England were the settings for this study.

PARTICIPANTS

Purposive sampling to ensure there was a mixed group of prescribers was used to enable detailed exploration of the research objectives and to obtain in-depth understanding of the complex activities involved in nurse prescribing.

METHODS

Interviews and case scenarios. The use of cognitive continuum theory guided the analysis.

RESULTS

The majority of participants were unable to identify the issues involved in all the scenarios; they also failed to provide an acceptable solution to the problem, suggesting that they would refer the patient to the general practitioner. A similar number described themselves as 'very confident' while seven participants felt that they were 'not confident' in dealing with medication issues, four of whom were practising prescribing.

CONCLUSIONS

The effects of social and institutional factors are important in the decision-making process. The lack of appropriate pharmacological knowledge coupled with lack of confidence in prescribing was demonstrated. The scenarios used in this study indicate that nurses are perhaps knowledgeable in their small area of practise but flounder outside this. Further research could be conducted with a larger sample and with more scenarios to explore the decision-making and the pharmacological knowledge base of nurse prescribers, particularly in the light of government policy to extend prescribing rights to non-medical prescribers, including pharmacists.

Introducing nurse prescribing in a memory clinic

Nurse prescribing has become increasingly important in allowing nurses to assume more proactive roles in ways designed to promote better self-care and concordance with medications by service users. At the moment, there is little evidence of how this can be accomplished in work with older people with cognitive impairments. In this article we consider the experiences of service users and family carers, based on a small-scale qualitative research study carried out during the early stages of implementing nurse prescribing from a memory clinic in Doncaster, UK. We conclude by reviewing the lessons learned from this formative evaluation.

Independent extended supplementary nurse prescribers, their prescribing practice and confidence to educate and assess prescribing students

BACKGROUND

No other country in the world has such extended prescribing rights for nurses as the United Kingdom. Concerns surround the move of nursing towards a medical model of care, and the level of medical practice support required by trainee prescribers.

AIM

To provide an overview of the nurses adopting the role of independent extended supplementary prescriber, their prescribing practice and confidence to educate and assess prescribing students.

METHODS

A convenience sample of 1187 independent extended supplementary nurse prescribers were sent a questionnaire. Eight hundred and sixty eight completed questionnaires were returned.

RESULTS

The majority (82%) of nurses worked in primary care. Eighty seven percent used independent extended prescribing and 35% supplementary prescribing. Most were qualified to degree level or higher and had over 10 years nursing experience. Seventy four percent felt confident to act as a mentor during the prescribing programme. More highly qualified nurses and those who had undertaken, or had access to continuing professional development, were statistically more likely to feel confident to adopt this role.

CONCLUSION

Appropriately qualified nurse prescribers might be best placed to support trainee prescribers. Exploration of the low uptake of supplementary prescribing and access to continuing professional development is required.

Evaluating nurse prescribers' education and continuing professional development for independent prescribing practice: findings from a national survey in England

BACKGROUND

The number of nurses able to independently prescribe medicines in England has risen steadily in recent years.

AIM

To evaluate the adequacy of nurses' educational preparation for independent prescribing and to describe nurses' experiences of their continuing professional development as prescribers in practice.

DESIGN AND METHOD

Postal questionnaire survey.

PARTICIPANTS

Random sample of 246 nurses registered as nurse independent prescribers with the Nursing and Midwifery Council.

RESULTS

The majority of nurses considered that the initial taught course element of their education programme met their needs, either to some extent (61% 151/246), or completely (22% 54/246). Most nurses (77% 190/246) received the specified 12 days support from their supervising medical practitioner and most were satisfied and positive about this experience. Nearly all of the nurses (>95%) reported that they were able to maintain a range of specified prescribing competencies in practice. Two thirds (62% 152/246) of the sample reported that they were receiving support/supervision for prescribing. Ninety five per cent (233/246) of the sample also reported that they engaged in self-directed informal continuing professional development, but only half of the sample had experience of formally provided professional development opportunities. Approximately half (52% 127/246) of the sample identified needs for continuing professional development.

CONCLUSION

This first national survey of the education and professional development experiences of nurse independent prescribers in England provides evidence which highlights areas in which national policy is working well, and also points up issues which may need addressing as the roll out of nurse prescribing continues. The study also highlights characteristics and issues that health care policy makers and nurse educationalists internationally may wish to consider in developing and refining their own nurse prescriber education programmes.

Expanded practice roles for community mental health nurses: what do consumers and carers have to say?

Community-based mental health as the primary focus of treatment has influenced more autonomous roles for mental health nurses. A limited literature suggests that this has resulted in the expansion of community mental health nursing into territory usually the exclusive domain of the medical profession. Consumers and carers are the two groups most affected by changes to service delivery; however, their views regarding the changing role of community mental health nurses have not been sought. This paper presents the findings of a qualitative study involving indepth interviews with Australian consumers (n = 4) and carers (n = 6) designed to explore their views and opinions about the expanded practice roles of community mental health nurses. Four main themes were identified: accessibility and convenience; relationship with clinicians; beneficiaries of expanded nursing practice; and, are nurses up to it? The findings suggest expanded practice roles are perceived positively by consumers and carers and therefore worthy of further investigation.

Impact of nurse prescribing: a qualitative study

AIM

This paper is a report of an investigation of the impact of prescribing on a group of recently qualified nurse prescribers in the United Kingdom.

BACKGROUND

The creation of advanced nursing roles, and specific skills such as nurse prescribing, has resulted in nurses taking on roles that have traditionally been associated with doctors. The non-doctor prescribing initiative is continually developing and many nurses are now able to prescribe independently from almost the same range of medicines as doctors. Despite the advantages that appear to stem from nurses prescribing, some nurse researchers have been cautious about the impact that prescribing may have on the nursing profession.

METHOD

Interviews were conducted during 2005 and 2006 with 45 nurse prescribers. All nurses had successfully qualified and registered as prescribers. Interviews were analysed thematically in line with the principles of grounded theory.

FINDINGS

Prescribing allows nurses to overcome difficulties in the healthcare system that previously delayed patients' access to medicines. Prescribing is viewed as more than an 'add on' to current roles, it complements many aspects of nursing and integrates previously diffuse aspects of the nursing role. This enables nurses to adopt a more holistic approach to patient care and prescribing. Prescribing has the potential to increase job satisfaction and autonomous working, with the result that nurses are more likely to involve patients in decision-making about their care.

CONCLUSIONS

Prescribing enhances nurses' knowledge about medication and increases their confidence to engage in prescribing decisions across the healthcare team. Nurse prescribing has the potential to improve service-user care, enhance collaboration and widen discussions about medicines. However, team members need to be prepared for the impact nurse prescribing could have on the dynamics of the multidisciplinary team. Preparatory information about nurse prescribing should be provided to all team members by trainee nurse prescribers. Information could include details about the proposed scope of future prescribing roles, allowing team members to consider how their roles could develop.

Supplementary nurse prescribing for patients with skin conditions: a national questionnaire survey

AIM

To examine the prescribing practices of supplementary nurse prescribers (working in both primary and secondary care) who prescribe medicines for patients with skin conditions and the factors that facilitate or inhibit this mode of prescribing.

BACKGROUND

Nurses work in a variety of roles, with varying levels of expertise, are involved in the treatment management of a broad range of skin diseases. Skin conditions are those for which independent nurse prescribers prescribe most frequently. The role of the nurse, limitations of the formulary and inter-professional relationships influence the prescribing practices of these nurses. There is no evidence currently available examining the impact and activity of supplementary nurse prescribing for patients with skin conditions.

METHODS

A convenient sample of 580 nurses who prescribed for skin conditions and were qualified supplementary nurse prescriber, self-completed a written questionnaire.

RESULTS

Five hundred and twenty (89.7%) nurses were based in primary care and worked in general practice. Four hundred and thirty-six (75%) held a degree level qualification or higher, 41 (7%) had specialist dermatology training and 512 (88.3%) had more than 10 years postregistration nursing experience. Supplementary prescribing was used by a minority of nurses. Nurses who had specialist dermatology training used this mode of prescribing most frequently. Doctor and pharmacists lack of understanding of supplementary prescribing, lack of peer support and clinical management plans prevented the implementation of this mode of prescribing.

CONCLUSIONS

Supplementary prescribing is used by a minority of nurses to treat skin conditions. A number of factors prevent nurses from using this mode of prescribing including lack of specialist training and lack of support in practice.

RELEVANCE TO CLINICAL PRACTICE

Specialist dermatology training, an understanding of supplementary prescribing by the members of the healthcare team, and support in practice are required if supplementary prescribing is to be implemented effectively for the treatment of skin conditions.

Prescribing by specialist nurses in cancer and palliative care: results of a national survey

BACKGROUND

This study investigates Macmillan nurses' views on nurse prescribing in cancer and palliative care and explores perceived motivators and barriers to training for and the implementation of this extended nursing role.

METHOD

National postal survey of 2252 Macmillan nurses in the UK.

RESULTS

A response rate of 70% (1575) was achieved. Eleven percent (168 of 1575) of Macmillan nurses surveyed were trained as extended formulary independent nurse prescribers. Half (88 of 168) of the Macmillan nurses who could prescribe from the extended formulary were prescribing, representing just 6% (88 of 1575) of the sample. Training deficits highlighted included poor organization and insufficient length, depth and specificity of courses (to meet the needs of nurses working in palliative care) and a lack of medical mentorship. Among Macmillan nurses who had not undergone extended formulary independent nurse prescribing training, 25% (335) perceived that prescribing was not part of their specialist nursing role. A further 40% (538) expressed reluctance to undergo training.

CONCLUSIONS

A clear lack of enthusiasm amongst specialist nurses in cancer and palliative care to undertake prescribing training was identified. It is noteworthy that half of the Macmillan nurses trained as extended formulary independent nurse prescribers were not prescribing. Since government targets for nurse prescribing are not yet being met, these findings raise important questions concerning whether extended nurse prescribing is likely to be a successful initiative in cancer and palliative care.

Children's nurses and nurse prescribing: a case study identifying issues for developing training programmes in the UK

AIMS AND OBJECTIVES

(1) To develop an insight into the opportunities and barriers to nurse prescribing for a case study of children's nurses. (2) To consider the implications of independent nurse prescribing for children's nurses and the potential for nurse prescribing to be developed in acute children's care settings. (3) To use research data to develop a training strategy.

BACKGROUND

Nurse prescribing in the UK is evolving and current initiatives aim to extend the range and scope of prescribing. Children's nursing presents interesting challenges because of off-license drugs. Successful nurse prescribing lies in practice area preparation, local policy and practice development and identifying precourse training needs.

DESIGN

Case study.

RESEARCH QUESTIONS

(1) What opportunities do children's nurses identify as being appropriate for nurse prescribing? (2) Can children's nurses identify the benefits of patient group directives and the different levels of nurse prescribing? (3) What preparation do children's nurses need for nurse prescribing?

METHODS

Focus group of health visitors/district nurses to inform a survey of 500 nurses working in acute and specialist care settings in a large Children's Hospital. Results. Focus group main themes - training, supervision and the development of confidence, record keeping, benefits of nurse prescribing, autonomous practice, the formulary and its use in practice. Response rate was 27%. Senior nurses and specialists identified potential benefits for their practice. Course content needed to focus on children, i.e. children's physiology and pharmokinetics. Children's nurses frequently advise junior medical colleagues on prescribing issues. Patient group directives are a useful alternative to prescribing.

CONCLUSIONS

The results provide an insight into the training needs of children's nurses and specialist nurses which may be used to develop nurse prescribing training and practice. Training may need to be targeted at senior nurses/specialist nurses initially to develop a critical mass to change organizational culture.

RELEVANCE TO CLINICAL PRACTICE

Pertinent for senior nurses responsible for developing children's nursing practice and services for children in acute settings.

The role of the nurse prescriber: the views of mental health and non-mental health nurses

Even though the introduction of the role of the nurse prescriber promises improved access to medicines and increased flexibility in the workforce, the take-up of this role to date has been variable across the UK. This questionnaire-based study sought to compare the expectations of two distinct groups of nurses, one from a mental health and the other from a non-mental health background prior to becoming prescribers. Non-mental health nurses were of the opinion that being able to prescribe would increase efficiency and maximize resources, while mental health nurses saw prescribing primarily in terms of the benefits to clients--increased choice, improved access to care, better information about treatments and better quality of care.

Perceptions and practice of concordance in nurses’ prescribing consultations: Findings from a national questionnaire survey and case studies of practice in England

BACKGROUND

The number of nurses able to independently prescribe medicines in England is increasing. Patient adherence to prescribed medicines remains a significant problem [Department of Health, 2000. Pharmacy in the Future: Implementing the NHS Plan. A Programme for Pharmacy in the NHS. Stationary Office, London]. Concordance-a partnership approach to medicine consultations-is advocated as an effective solution [Medicines Partnership, 2003. Project Evaluation Toolkit. Medicines Partnership, London].

OBJECTIVES

To investigate whether nurses were practising the principles of concordance within their prescribing interactions.

DESIGN

Phase (i) postal questionnaire survey. Phase (ii): case studies of practice.

SETTINGS

Phase (i) primary and secondary care trusts throughout England in which nurse prescribers were practicing. Phase (ii) six general practice settings; one community midwifery service; one specialist community palliative care service; one secondary care ophthalmology unit; one NHS walk-in centre.

PARTICIPANTS

Phase (i) a random sample of 246 nurses registered as independent nurse prescribers with the Nursing and Midwifery Council in 2002/2003. Phase (ii) purposively selected sample of 14 nurse prescribers who participated in Phase (i) of the study; a total of 208 purposively selected patients completed self-administered questionnaires.

METHODS

Phase (i) postal questionnaires. Phase (ii) structured non-participant observation of 118 nurse prescribing consultations; 115 post-consultation patient questionnaires; 93-patient postal questionnaires.

RESULTS

99% of the nurses in the national survey stated they were practising the principles of concordance. The majority of patients surveyed also reported experiencing concordance in practice. Observation of practice revealed that although some principles of concordance were regularly integrated into nurses' practice, other principles were less often in evidence. Some evidence from both observation of practice and patient questionnaires suggested that a professionally determined 'compliance' agenda may still be partially operating in practice.

CONCLUSIONS

Most nurses believe they are practicing concordance in their prescribing consultations. The majority of patients also reported that they had experienced some of the principles of concordance in practice. Observation of practice highlighted that the shift from a professionally determined compliance agenda to the integration of concordance into nurses' prescribing consultations had not yet taken place.

Nursing and public participation in health: an ethnographic study of a patient council

BACKGROUND

Conceptualisations of the nurse-patient relationship tend to view nursing as embodying an empowering approach to patients, one that places the service user perspective at the centre of decision-making. However, the relationship of nursing to public participation in health service planning and development has been under examined.

AIMS

The aim is to explore the relationship of the nursing profession to public participation as enacted through a UK-based patient and public council, located in an acute hospital. The council was developed by nursing staff and aimed to achieve service user participation in strategic level health care decision-making. The views and experiences of participants and the applicability of the 'nurse-patient partnership' construct to public participation are considered.

METHODS

The study employed integrative ethnography, involving multiple field methods: non-participant observation of council meetings, i.e. fourteen 3 h meetings (n=42 h); in-depth interviews with councillors (n=17) and with key hospital staff (n=18). A documentary review and mapping of the actions of the council was undertaken.

RESULTS

A nurse-patient partnership was not initially intrinsic to the operation of the council or embedded in the perspectives of the nurse or patient participants. Professional vulnerability and the organisational context constrained the nursing response. Councillors and nursing staff moved to create a shared set of understandings in order to progress change in service organisation and delivery. Nurses' repositioning vis-à-vis the credibility of user experiences and status was central to the effective progression of the council.

CONCLUSIONS

Partnership in public participation requires a shift by nurses' towards acceptance of members of the public functioning as informed, critical and powerful agents in health care decision-making. Equipping nurses with the skills to communicate with patient representatives in a position of interactional equality is likely to be a pre-requisite for successful engagement by nursing with public participation.

Preparing nurses to prescribe medicines for patients with dermatological conditions

BACKGROUND

From Spring 2006, independent extended nurse prescribers in the United Kingdom will be able to prescribe any licensed medicines except controlled drugs. Supplementary nurse prescribers are currently able to prescribe any medication. No other country in the world has such extended prescribing rights for nurses. Aspects of prescribing viewed positively by nurses include continuity of care, increased satisfaction, and the belief that patients receive improved information about prescriptions. There is some evidence, however, that nurses feel ill-prepared to prescribe due to poor understanding of pharmacology, physical assessment and diagnosis.

AIM

This paper reports a study assessing the extent to which independent extended supplementary nurse prescribers feel prepared to prescribe medicines for patients with dermatological conditions.

METHODS

A convenience sample of 1187 qualified independent extended supplementary nurse prescribers was sent a postal questionnaire. A total of 868 completed questionnaires was returned, and 638 of these nurses prescribed medicines for skin conditions. The data were collected in 2005.

RESULTS

A total of 605 (94.8%) participants used independent extended prescribing and 234 (36.7%) supplementary prescribing. The majority were highly experienced and worked in primary care. In general, their prescribing programme had met their needs when prescribing medicines for patients with dermatological conditions. However, the needs of those who had undertaken a diploma-level module in dermatology and/or dermatology study days, and those working in both primary and secondary care, were met to a statistically significantly greater extent during the programme than for those nurses without this preparation, or those working in either primary or secondary care.

CONCLUSION

Independent extended supplementary prescribing has extended the role that nurses in the United Kingdom are able to play in the management of skin disease. Specialist dermatology training is a prerequisite for nurses adopting this role. Further evaluative work on patient-focused outcomes, i.e. accessibility and convenience of care, and satisfaction with quality of care, is required.

Non-medical prescribing in nurse-led community leg ulcer clinics

Over the past decade, nurse prescribing in the community has improved clinical care, providing timely access to many products required for patients to receive appropriate treatment. Until recently, nurses who have qualified as nurse prescribers have only been able to prescribe from a limited list of products. Within the leg ulcer clinic environment, the majority of prescriptions written have been related to wound care. This article describes the introduction of extended independent prescribing (now known as non-medical prescribing) and how this type of prescribing has scope for revolutionizing clinical practice in all healthcare settings. There are, however, many contentious issues for clinicians prescribing in this new role, including systems for communication, clinical governance, and attitudes of other professionals.