Authors Kathy Davis, PhD, BSc, SRN, is postdoctoral research fellow, Consortium for Healthcare Research, City University, London; Vari Drennan, PhD, MSc, BSc, RN, RHV, is professor of health policy, Faculty of Health and Social Care Sciences, Kingston University and St George’s Hospital Medical School, London.
ABSTRACT Davis, K., Drennan, V. (2008) Nurse prescribing: national data analysis. Nursing Times; 104; 5: 46–48.
Kathy Davis and Vari Drennan summarise the results of an investigation into the prescribing behaviours of community-based nurses and GPs, using prescribing in constipation as a case study (Davis and Drennan, 2007).
Independent non-medical prescribing in the UK has evolved in a number of forms. The first nurses to gain independent prescribing rights had to have health visiting or district nursing qualifications before obtaining a nurse prescribing qualification that prepared them to prescribe from a limited nurse prescribers’ formulary (NPF). Since 2007, any registered nurse can undertake the short nurse prescribing qualification to prescribe from the NPF.
In 2003, legislation permitted any registered nurse to undertake a longer prescribing course and prescribe from a broader nurse prescribers’ extended formulary (NPEF). Legislation discontinued this formulary from May 2006. Appropriately qualified nurses can now prescribe across the full British National Formulary (BNF), including a limited number of controlled drugs, provided they prescribe within their competencies.
While there is increasing evidence that nurse prescribing is effective and improves patient care, empirical data investigating other aspects – such as nurse prescribing behaviour and clinical outcomes or comparing these between non-medical and medical prescribers – is limited.
Aims and method
This study aimed to explore patterns of nurse prescribing over time and investigate whether prescribing behaviour was influenced by contextual factors. It used the medical management of constipation as a case study.
This area was chosen for a number of reasons:
It is a common condition;
There are UK guidelines on step-wise best practice in its management;
Nurses are involved in its management or advising on this in many patient groups;
Some laxatives are included in the NPF so have been available to nurse prescribers since legislative authority to prescribe was first available.
The investigation undertook a secondary analysis of prescribing analysis and cost tabulation (PACT) data in England. This is collated by the Prescription Pricing Authority (PPA) from every NHS prescription dispensed in primary care. It is used for monitoring and financial planning purposes. The data differentiates between nurses employed by general practices (practice nurses) and those employed by PCTs.
Data was requested and provided by the PPA under the terms of the Freedom of Information Act 2000 for all nurse and GP prescriptions for items in the BNF laxative category dispensed between July 2004 and June 2005. The analysis was descriptive by type of prescriber (nurse employed by a PCT or general practice), type of formulary used, category of items, strategic health authority area and time trends.
Between July 2004 and June 2005, 6,241 nurses were prescribing items for constipation. Of these, 83% were employed by a PCT and 17% by general practices. Each month in this period, an average (mean) of 28,838 GPs were prescribing laxative items. The number of nurse prescribers by NHS region showed a wide variation: in Cumbria and Lancashire (an area of 9,300km2 and a population of about 1.9 million) 364 nurses prescribed laxative items in the year, compared with 91 nurses in North East Thames (an area of about 25km2 and a population of about 4.4 million).
A total of 37,467 laxative items were prescribed by nurses in the study period. Each month the mean number of items prescribed by nurses was 3,122: in comparison, the mean number prescribed by GPs was 913,181 across the four BNF laxative categories (bulk-forming agents, stimulant and osmotic laxatives and stool softeners).
Overall, the PCT-employed nurses prescribed 85% of all laxative items. The practice-employed nurses predominantly prescribed items listed in the NPEF and the PCT-employed nurses from the NPF, which had a restricted list of items from each laxative category. One notable omission among the wider range of products in the NPEF was the macrogols (polyethylene glycols), such as Movicol from the osmotic laxative category.
The trend over the 12-month period was for the number of items per month prescribed by PCT-employed nurses to decrease (2,961 in July 2004
to 2,590 in July 2005), and the number of items prescribed by practice-employed nurses to increase (413 to 747). The number of items prescribed by all nurses prescribing from the NPEF rose from 690 to 1,136 items. By comparison, the number of items prescribed by nurses using the NPF was almost static over the 12-month period ranging on a monthly basis from 2,157 to 2,684 items.
Differences were also observed in prescribing behaviours between the PCT and practice-employed nurse groups, and between nurses and GPs. Irrespective of employment or formularies used, most items prescribed by nurses were osmotic laxatives (70%) and the next most frequent category were stimulant laxatives (22%). This contrasts with GP prescribing in that 45% of the items they prescribed were from the stimulant laxative category, followed by 36% in the osmotic laxative category. Nurses with access to the wider range of items through the NPEF prescribed a greater proportion of their items from the stimulant laxative category than those with access only to the restricted NPF, although the difference was not statistically significant.
Discussion and conclusion
This descriptive analysis of a national prescribing data set has enabled, for the first time, nurse prescribing in England to be explored in detail. Overall, the volume of nurse prescribing was a fraction of that undertaken by GPs, who annually prescribe 11 million laxative items.
The first finding was that the number of nurses prescribing items for constipation was small compared with those holding prescribing qualifications (16.6% of those with NMC-recorded nurse prescribing qualifications in 2006). This is of particular interest as 80% of the UK adult community nursing workforce manage patients with constipation. Possible explanations include: insufficient numbers of nurse prescribers (regional variations in prescribing may support this); nurses are choosing not to prescribe because of administrative and interprofessional obstacles; and nurses are prescribing medicines but also exercising clinical judgment and advising first-step approaches such as diet and lifestyle changes.
The second finding was of an upward trend in the number of items prescribed by practice-employed nurses, and a downward trend in the number of items prescribed by PCT-employed nurses. The upward trend may just be a function of the increased numbers of practice-based nurses with prescribing qualifications or may reflect a change in the case-mix of patients consulting these nurses.
The downward trend in the number of items prescribed by PCT nurses is unlikely to be the result of a changed case mix of patients but may reflect the reducing numbers of nurses in community nursing services with the first type of prescribing qualifications as the early cohorts retire or move to new posts.
The variation in categories of laxatives prescribed between those employed in PCTs or by practices may reflect the different patient case-mix, although access to a wider choice of products appears to influence prescribing irrespective of employment.
Differences were observed between GP prescribing and the nurse prescribing in the type of laxative categories prescribed. Without further empirical study at patient level, it is impossible to comment on the extent to which clinically appropriate and pharmacologically effective prescribing was exercised by any group.
There has been an incremental growth in non-medical prescribing in the UK over the past 10 years. This investigation shows that low numbers of nurse prescribers are exercising their prescribing rights for a common condition that often involves nurses in patient management or education. It also shows that there are different trends in prescribing practices between nurses employed in general practice and with access to an extended formulary, and those with access to a limited formulary.
This investigation is limited by the nature of the data set and, although its findings are illuminative, they cannot provide explanations or be generalised more widely. Instead the analysis raises questions and the findings cannot be adequately explained without further supporting data such as the link to clinical decision-making, the patient’s perspective and treatment-related outcome measures. Future investigation of nurse prescribing behaviour is planned, linking prescription data to patient level data.
Davis, K., Drennan, V . (2007) Evaluating nurse prescribing behaviour: using constipation as a case study. International Journal of Nursing Practice; 13: 4, 201–265.
The full study was published in the International Journal of Nursing Practice (Davis and Drennan, 2007). At the time of this study Kathy Davis PhD, BSc, SRN, was a research fellow at PCNRU; Vari Drennan PhD, MSc, BSc, RN, RHV, was the director of Primary Care Nursing Research Unit, at the Department of Primary Care and Population Sciences, University College, London
Department of Health (2006) A Prescription for Patient Satisfaction. www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4134390
Department of Health (2005) Nurse and Pharmacist Prescribing Powers Extended. London: Department of Health. www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4122999
Department of Health (2001) Patients Get Quicker Access to Medicines. London: Department of Health. www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4010748
Prodigy (2005) Constipation. Newcastle: Sowerby Centre for Health Informatics. www.prodigy.nhs.uk/constipation/extended_information/management_issues