Nurse prescribers have a greater role than ever but barriers need to be overcome in order to encourage nurses to undertake prescribing training and realise their potential
A legislation amendment in 2012 has increased the role of independent nurse prescribers. However, both internal and external barriers remain that prevent nurses from undertaking nurse prescribing training. This article discusses these barriers and offers suggestions on how to overcome them and encourage more nurses to undertake the training.
Citation: Blanchflower J et al (2013) Breaking through barriers to nurse prescribing. Nursing Times; 109: 31/32, 12-13.
Author: Jim Blanchflower is lecturer, Leah Greene is hi-fidelity simulation laboratory manager, and Christine Thorp is lecturer; all at the University of Salford.
- This article has been double-blind peer reviewed
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Since 1994, district nurses, midwives and health visitors have been able to prescribe from a limited formulary. New legislation in 2003 allowed nurses to become supplementary prescribers and further changes in 2006 meant they could become independent nurse prescribers (INPs) after appropriate training. In 2012 an amendment was made allowing INPs to prescribe controlled drugs listed in schedules two to five of the 2001 regulations, overcoming what many thought to be the final great obstacle to nurse prescribing. As a result, the numbers of INPs in England has continued to rise.
Despite this progress, nurses are not prescribing as expected - even after training. They have often been slow to take up the opportunity to train as prescribers (Bradley et al, 2008) and, when they have trained they have continued to face barriers to prescribing (Kroezen et al, 2012).
Increased nurse prescribing benefits patients and trusts in a number of ways, including reducing treatment delays and prescribing being undertaken by individuals in areas of personal expertise. Bearing these benefits in mind, it is strange that nurses who are qualified to prescribe still face difficulties in doing so.
Following a literature search, we identified the key factors acting as barriers to nurse prescribing. These can be examined under two general headings:
- Internal: arising from the individuals themselves;
- External: imposed on the individuals by others or by their environment.
The distinction between internal and external factors is, to an extent, an artificial one. Some of the factors discussed will cross the boundaries between the two.
Confidence in the ability of the nurse to prescribe independently and safely is an important issue for everyone involved. Nurses should feel they have had sufficient training and have adequate understanding to manage medicines effectively. Other health professionals, as well as patients, also need to be satisfied that the nurse is able to select the best medicines and to successfully manage the treatment afterwards. It has been found that patients do have this confidence in nurse prescribers, possibly reflecting a confidence in their clinical knowledge (Stewart et al, 2009).
It is reasonable to expect there would be concerns over safety, particularly with INPs. However, in 2012, a small study found that 75% of nurse prescribers met the Department of Health’s UK standards for safety (Gumber et al, 2012). The remaining 25% reported they did not receive regular supervision, highlighting the need for more work in this area.
Effective communication between the nurse prescriber, the patient and, if the nurse is a supplementary prescriber, the designated medical practitioner who acts as mentor is crucial to effective prescribing.
In the absence of all other barriers, it may be that apathy is a factor in preventing nurses from accessing prescriber training (Cooper et al, 2008).
There is a real need for nurse prescribing as it meets the demands of an increasing number of patients at a time when budgets are being tightened. Allowing nurses to prescribe makes the service more patient-centred (Pirie and Green, 2007), but it is possible that not all stakeholders recognise this need.
Education could be regarded as a potential barrier or as an enabling factor, depending on how well it addresses the needs of nurse prescribers. Busy schedules and logistic issues can prevent continuing professional development. When pharmacology training is able to go ahead, it is difficult to deliver CPD that is relevant to all prescribers due to the numerous specialisms (Carey and Courtenay, 2010).
Conflict between professions
Conflict between mental health nurse prescribers and psychiatrists has been reported (Gumber et al, 2012). Doctors are traditionally considered to be at the top of a hierarchy and are notoriously protective of their power and prestige (Kroezen et al, 2012). Rana et al (2009) stressed the importance of trusts working with all professions to make the transition towards new roles for prescribers, concluding that without careful consideration, changes could increase conflict between the professions.
The attitudes of patients, other health professionals and the nurse prescribers themselves are an important factor in the success of nurse prescribing. Managers who are not very sympathetic could act as obstacles to prescribing - some managers may not allow CPD in work time or may not fully understand the requirements for CPD in nurse prescribing.
Bower (2007) found that some nurses, once they had qualified as INPs, were having problems with local policies, such as a failure to amend job descriptions or only allowing nurses to use supplementary prescribing. In order to overcome this, nurse prescribing should be an integral part of workforce planning.
In order to facilitate the implementation of nurse prescribing it is clear that the policies involved, both nationally and locally, must support it. In the past, some trusts have been slow to implement nurse prescribing and some did not alter policies to enable it (Bower, 2007).
Legislation also needs to address the issue of accountability for any mistakes that are made in the prescribing process. Concerns over whether nurse prescribers would have to meet the same set of standards as doctors have been raised by nurses in the past (Buckley et al, 2006). These standards would include issues such as accountability and legal status.
It may be appropriate to build management of medicines into the curriculum for pre-registration student nurses to encourage and facilitate the uptake of nurse prescribing training. It could also help to encourage the change in culture that is needed to make nurse prescribing the norm.
CPD training should be flexible so it can be tailored to the requirements of the individual and include conferences, lectures and informal discussions with other staff as well as formal education programmes.
It is imperative that INPs know their limitations with respect to their personal area of expertise. It is not enough that nurse prescribing should be safe; it needs to be seen, and proven to be safe. The research evaluating safety should be maintained in order to develop greater confidence for all stakeholders. Nurse prescribers can keep up to date with advancements in clinical knowledge by registering with the NICE Evidence Search.
Support from other professions is needed for nurse prescribing to flourish. The prescribers themselves must be motivated, enthusiastic and have a drive to succeed. Similarly, employers need to offer supportive and operational infrastructures, while shared vision, local championship, action learning and team support are also needed (Jones et al, 2011).
Despite rapid growth and success of nurse prescribing, some challenges still remain. These may be overcome by increasing the number of nurse prescribers, which would: increase support within teams; help bring about changes in attitude and culture; and, as the market for CPD increases, make it more cost effective for education providers to address nurse prescribers’ specific needs.
The most important clinical outcome in judging the success of nurse prescribing should be patient benefits, but this is harder to quantify than measures such as the number of prescriptions written. Researchers should continue to investigate ways to make nurse prescribing safer and more effective, as well as how to facilitate its implementation.
- Nurse prescribing leads to a reduction in treatment delays and means prescribing is done by individuals within areas of personal expertise
- Often employers do not recognise the importance of continuing professional development for nurse prescribers
- Conflict between professions can arise from increasing nurses’ responsibilities
- Barriers still exist to nurses becoming prescribers
- The most important clinical outcome in judging the success of nurse prescribing should be patient benefits
Bower E (2007) There are still barriers to nurse prescribing. Independent Nurse; April.
Bradley E et al (2008) Putting mental health nurse prescribing into practice. Nurse Prescribing; 6; 1, 15-19.
Buckley P et al (2006) Inter- and intra-professional perspectives on non-medical prescribing in an NHS trust. The Pharmaceutical Journal; 277, 394-399.
Carey N, Courtenay M (2010) An exploration of the continuing professional development needs of nurse independent prescribers and nurse supplementary prescribers who prescribe medicines for patients with diabetes. Journal of Clinical Nursing; 19, 208-216.
Cooper RJ et al (2008) Nurse and pharmacist prescribing in the UK: a thematic review of the literature. Health Policy; 85: 3, 277-292.
Gumber R et al (2012) Non-medical prescribing audit, practice and views. Journal of Psychiatric and Mental Health Nursing; 19: 6, 475-481.
Jones K et al (2011) Nurse prescribing roles in acute care: an evaluative case study. Journal of Advanced Nursing; 67: 1, 117-126.
Kroezen M et al (2012) Nurse prescribing of medicines in western European and Anglo Saxon countries: a survey of forces, conditioning and jurisdiction control. International Journal of Nursing Studies; 49: 8, 1002-1012.
Pirie E, Green J (2007) Should nurses prescribe blood components? Nursing Standard; 21: 35-41.
Rana T et al (2009) Survey of psychiatrists’ views of nurse prescribing. Journal of Psychiatric and Mental Health Nursing; 16: 257-262.
Stewart DC et al (2009) A cross sectional survey of the Scottish general public’s views on and attitudes to nonmedical prescribing. Annals of Pharmacotherapy; 43: 1115-1121.