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Addressing the concerns of the trainee nurse prescriber

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The Department of Health (DH) has invested heavily in nurse prescribing, stating in 1999 that it should be seen as part of the NHS modernisation agenda.

Abstract

VOL: 102, ISSUE: 11, PAGE NO: 36

Eleanor Bradley, PhD, MSc, BSc, CPsychol, is senior research fellow, Faculty of Health and Sciences

Peter Nolan, PhD, Med, BA, BEd, RMN, RGN, DN, RNT, is professor of mental health nursing; both at Staffordshire University

The Department of Health (DH) has invested heavily in nurse prescribing, stating in 1999 that it should be seen as part of the NHS modernisation agenda.

 

 

Despite such encouragement and support, non-medical prescribing has not been embraced by all nursing specialties nor by all healthcare trusts. The National Prescribing Centre (NPC) has noted that mental health trusts in England have not been consistent in taking prescribing on board (Jones and Jones, 2005).

 

 

Literature review
The literature relating to the implementation of non-medical prescribing is increasingly focused on nurse prescribing within specialties rather than within the profession as a whole (Hennell et al, 2005; Gibson et al, 2003; Davis and Hemingway, 2003).

 

 

The DH has taken the view that nurses will prescribe within their sphere of competence and that different formularies are therefore not required (Cox et al, 2003).

 

 

It has been claimed that nurse prescribing has benefits for both service users and nurses. Studies from the US suggest that it improves access to services for disadvantaged people (Warner, 2005; Saur and Ford, 1995). Service users have reported that nurse prescribers have more time than doctors to discuss treatment and provide higher quality care (Mundinger et al, 2000). Nurses enjoy improved job satisfaction (Duffin, 2005) and greater flexibility in how they approach their work (Warner, 2005).

 

 

A survey of advanced practice nurses in the US suggested that prescribing was a positive experience that saved time and increased professional autonomy (Latter and Courtenay, 2004).

 

 

Alongside these benefits, various concerns have been raised. McCartney et al (1999) have suggested that the nurse prescribing initiative is driven by the need to reduce costs by transferring mundane tasks to nurses and the desire to undermine the power of the medical profession. Harrison (2003) found that mental health service users in the UK were cautious about whether nurses had the skills and knowledge to undertake an extended role and were concerned that diagnosis and treatment would displace core nursing activities. Concerns about the adequacy of nurses’ pharmacological knowledge have also been raised by nurse prescribers in the US (Latter and Courtenay, 2004). King (2004) suggested that this problem should be tackled at undergraduate level with an increase in pharmacological input in the pre-qualification curriculum.

 

 

Support for nurses following qualification is equally important to the training of nurse prescribers. Clinical supervision in particular is vital to ensure that nurses are engaging in evidence-based prescribing (Jones and Jones, 2005; Humphries and Green, 2000). As well as formal support sessions, informal support from peers, GPs and pharmacists is crucial if nurses are to feel encouraged to use their prescribing powers (Warner, 2005).

 

 

A better understanding of how prescribing impacts on the time nurses spend providing medication-related care and on their status as autonomous practitioners is needed. In addition a clear idea of the challenges nurses feel they face prior to having training in prescribing and on starting to prescribe would enable appropriate support to be put in place.

 

 

Method
This article reports on two questionnaire surveys that were part of a three-year evaluation of nurse prescribing across the West Midlands. The first survey provided a profile of the nurses presenting for prescribing training and explored their reasons for doing the training. The second survey questioned qualified nurse prescribers about how prescribing had helped them develop their role.

 

 

The study received multicentre research ethics committee (MREC) approval and permission was granted to approach students through higher education institutes (HEIs). The project was registered with local NHS trusts in line with research governance guidelines.

 

 

Pre-training questionnaire results
Overall 387 nurses responded to the questionnaire. The mean age of the sample was 42 years (range: 25-59 years) and the mean time the nurses had been qualified was 18 years (range: 3-40 years). Their specialties are listed in Table 1.

 

 

Anticipated prescribing area

 

 

The nurses were asked which prescribing role (supplementary or independent) they would be taking on once qualified. A total of 141 respondents (36.5%) were primarily interested in supplementary prescribing, 114 (29.5%) in independent prescribing, and 131 (33.9%) were interested in using both supplementary and independent prescribing.

 

 

The nurses were asked where they worked and their workplaces were compared with the prescribing roles that they anticipated taking on. Respondents working in a hospital or community setting anticipated using the supplementary qualification principally, although almost as many anticipated using the independent qualification or both. Respondents working in GP settings felt that they would be working as both independent and supplementary prescribers.

 

 

Medication-related care and decisions

 

 

Nurses were asked to use Likert-type scales to estimate the frequency of their involvement in medication-related care (Table 2), prescribing decisions (Table 3, p38), and the proportion of time spent working autonomously (Table 4, p38).

 

 

They were asked whether they felt prescribing would advance their practice. Most (n=376; 97.2%) felt it would and only eight (2.1%) felt it would not. When asked whether prescribing would increase their autonomy, 354 (91.5%) felt that it would, while 28 (7.2%) felt that this was unlikely. Questioned on whether prescribing would help to improve patient care, 378 (98.4%) felt that it would, and 6 (1.6%) felt that it would not.

 

 

Areas of concern

 

 

Nurses were asked to outline any concerns they had about becoming prescribers. These were:

 

 

- Availability of appropriate support, n=56;

 

 

- Lack of knowledge, n=44;

 

 

- Limited nurse prescribers’ formulary, n=29;

 

 

- Misconceptions about nurse prescribing, n=26;

 

 

- Safety, n=26;

 

 

- Increased workload, n=22;

 

 

- Using the clinical management plan, n=22;

 

 

- Inadequate policies to support prescribing, n=22;

 

 

- Legal issues/indemnity, n=18;

 

 

- Whether colleagues and patients will accept nurses as prescribers, n=16;

 

 

- Accountability, n=16;

 

 

- No remuneration for extra responsibility, n=15;

 

 

- How to implement the prescribing role, n=13;

 

 

- Whether colleagues will abuse the role, n=12.

 

 

Concern about being sufficiently well supported was a major concern. From the open-ended questions it would appear that nurses want both informal and formal support from their colleagues and their organisations.

 

 

Post-training questionnaire results
A minimum of seven months after respondents qualified as prescribers, 136 questionnaires were sent out and 71 (52%) were returned. A total of 55 nurses (77%) had prescribed medication since qualifying and 16 (23%) had not. Of those who had prescribed, 17 (23.9%) had acted as supplementary prescribers, 22 (31%) as independent prescribers, and 15 (21%) as both.

 

 

Medication-related care and decisions

 

 

Respondents were asked to outline how they felt prescribing had affected the frequency of their involvement in medication-related care (Table 5, p39) and the amount of clinical work they undertook autonomously (Table 6, p39).

 

 

In response to further questions, 63 nurses (89%) felt that prescribing had advanced their practice, 62 (87%) felt that it had increased their autonomy and 63 (89%) felt that prescribing had helped them to improve patient care.

 

 

Areas of concern

 

 

Nurses’ responses to a question about whether they had any ongoing concerns were:

 

 

- Limitations of formulary, n=10;

 

 

- Time for CPD, n=8;

 

 

- Lack of support, n=6;

 

 

- Having confidence to prescribe, n=6;

 

 

- Undeveloped policies, n=5;

 

 

- Availability of supervision, n=3;

 

 

- Lack of assessment skills, n=2;

 

 

- Misunderstanding of role, n=2;

 

 

- Lack of remuneration, n=1;

 

 

- Increased workload, n=1.

 

 

Discussion
Half of the nurses who took part in this study came from practice nursing, mental health nursing, district nursing and paediatric/neonatal nursing. The large number of practice and district nurses who came forward is unsurprising. The large number of mental health nurses is surprising in national terms but not in relation to the region in which the study was conducted. Where there are only one or two nurses from individual specialties, questions must be asked about the selection of candidates and the support available to them, as well as the impact that a single nurse could have.

 

 

Most nurses who took part in this study stated that they were already spending time every day in medication-related care and contributing regularly to prescribing decisions. Training therefore appeared merely to be formalising this ‘informal’ prescribing role. Just over half of the respondents felt that 70-100% of their work was undertaken autonomously, leaving nearly half with scope to increase autonomy through prescribing.

 

 

Further work is now needed to establish whether, as Harrison (2003) has suggested, medication-related care with its associated diagnostic and treatment skills is displacing core nursing care. Interestingly these respondents did not cite such displacement as a concern. Perhaps prescribing is still too new a role for nurses to anticipate what the longer-term consequences of it might be.

 

 

The respondents attending the prescribing courses voiced concerns about whether they had sufficient pharmacological knowledge to prescribe. However, once qualified this concern gave way to others, suggesting that the training courses do meet nurses’ educational needs. Post-qualification, concerns about support through formal and informal mechanisms became much more prominent, as did anxiety about the way in which their role would be perceived by colleagues. There was recognition that prescribing would increase workload for no additional remuneration. These concerns have previously been highlighted by McCartney et al (1999).

 

 

Most of the nurses felt that prescribing was improving patient care and would enhance their future development as autonomous practitioners. These results may reflect the fact that most respondents were attached to the trust mentioned above in which nurse prescribing is well established. Managerial support and funding are required if nurses are to find the confidence to undertake prescribing training. Ongoing support following qualification is essential, coupled with education and communication to promote nurse prescribing across teams.

 

 

In trusts that are strongly supportive of non-medical prescribing, it appears from the results of this study that nurses will put their prescribing qualification into effect. More than three-quarters of the nurses surveyed had acted as prescribers since qualification. Despite some early reports that the supplementary prescribing role was cumbersome in practice, more than half of the nurses who took part in this study had utilised it to some extent. It will be interesting to see whether the supplementary prescribing role will continue to be used when the remit of prescribing is extended in 2006, or whether nurses working in areas such as mental health will prefer to prescribe independently.

 

 

This survey suggests that nurse prescribing is increasingly being seen as a means to enhance the role of nurses and assist them in delivering top quality patient care. While support is still a key issue and likely to remain so for some time, especially in trusts where non-medical prescribing is still in its infancy, nurses’ confidence to prescribe in trusts where non-medical prescribing is well established seems to be strong. Initial concerns about nurses’ lack of knowledge of pharmacology do not seem to be as prominent following training. Research now needs to explore the impact of nurse prescribing on service users. A range of issues should be addressed, such as:

 

 

- What kind of information do nurses provide about medication?

 

 

- Does nurse prescribing improve concordance?

 

 

- Do nurses spend more time than doctors with service users discussing their medication?

 

 

- Does the addition of prescribing to nurses’ duties mean that they have less time for this and other aspects of the nursing role?

 

 

As the numbers of non-medical prescribers increase, it will be important to examine from which health professionals service users prefer to receive their medication and why.

 

 

Limitations

 

 

There are limitations to this study. A large proportion of respondents (54%) were studying at one of the five HEIs. Respondents were therefore focused in one geographical region and the organisations within this region, lessening the generalisability of the findings. The response rate to our postal questionnaire was disappointing (52%). Postal questionnaires were not sent to nurses until they had been qualified as prescribers for at least seven months and many addresses were no longer accurate.

 

 

Conclusion
With the right support systems in place, nurse prescribers are utilising their prescribing skills to develop their role, increase their clinical autonomy and improve patient care. Organisations must demonstrate their commitment to non-medical prescribing by putting the appropriate support and educational measures in place. Nurses themselves must assess whether prescribing can be integrated into their practice or whether it threatens to displace the traditional care they have provided.

 

 

This article has been double-blind peer-reviewed.

 

 

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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