Evaluating the impact and efficacy of nurse prescribing at an acute trust in England
In this article…
- An evaluation of nurse prescribing roles at an acute trust
- Experiences of nurse prescribers and how the role is viewed by other health professionals and patients
- A model for implementing role changes in clinical practice
Kathryn Jones is deputy director of nursing, Imperial College Healthcare NHS Trust; Margaret Edwards is senior lecturer and Alison While is professor of community nursing, both at King’s College London.
Jones K et al (2011) The effectiveness of nurse prescribing in acute care. Nursing Times; 107: early online publication.
Background The role of nurse prescriber has been recognised in the community since the 1990s but it was only in 2002 that it was extended to acute care. At the time of the study, little was known about the impact and effectiveness of nurse prescribing in the acute setting.
Aim To evaluate the implementation of nurse prescribing roles at an acute trust in England.
Method A mixed-methods, single-case study was carried out in 2005–06. Semi-structured interviews were conducted with 18 hospital staff, two doctors and two nurses undertaking 52 patient–prescriber consultations involving 47 patients were observed, and 74 patients were surveyed using a questionnaire.
Results Nurse prescribing was found to benefit patients through improvements in service delivery and better use of staff skills. No differences were found between the ways in which doctors and nurses performed prescribing roles but there was a statistically significant difference between the medicine-related satisfaction ratings of patients seen by a nurse compared with those seen by a doctor.
Conclusion Nurses and doctors provided equivalent care. Nurse prescribers were crucial to the success of the initiative because of their enthusiasm, motivation, drive to succeed and a shared vision supporting prescribing roles.
Keywords: Nurse prescribing, Medical prescribing, Acute care, Service delivery
- This article has been double-blind peer reviewed
5 key points
- Nurse prescribing benefits patients through improvements in service delivery and better use of staff skills. It also impacts positively on team working
- There are no significant differences between the way nurses and doctors perform the prescribing role
- Patients seen by a nurse prescriber report higher rates of medicine-related satisfaction than those seen by a doctor
- Supportive team working, strategic nurse leadership and action learning are key to the successful implementation of prescribing roles
- Employers should ensure supportive and operational infrastructures are in place to underpin role changes
Nurse prescribing has been a recognised role for district nurses and health visitors since the early 1990s, but was only extended to nurses working in acute care in 2002 (Department of Health, 2002). According to the DH (2006), non-medical prescribing benefits patients by providing more efficient access to medicines, and puts staff skills to better use. This article presents an evaluation of nurse prescribing roles in acute care and proposes a model for identifying the variables that need to be considered before new roles are implemented.
The study was carried out between July 2005 and September 2006 at an acute trust in England. At the time of the study, some researchers had evaluated the impact and effectiveness of nurse prescribing in primary care (Latter et al, 2005; Latter and Courtney, 2004), but little was known about its use in other settings. A case study approach was taken to explore and evaluate the implementation of seven new nurse prescribing roles in an acute hospital setting. Specific study objectives were informed by a review of the literature and by propositions from clinical practice.
The study explored:
- The purpose of nurse prescribing roles;
- The experiences of nurse prescribers and their teams; and
- The differences between the roles of medical and nurse prescribers.
Purpose of nurse prescribing roles
Interviews were carried out with 18 hospital staff employed in strategic or operational roles that were relevant to the implementation of nurse prescribing. This included three nurse prescribers; seven of their medical, nursing and pharmacy colleagues; and eight senior trust staff.
Overall, participants expressed positive views about nurse prescribing, making specific comments about the benefits and costs of its implementation for staff, patients and the wider organisation. Themes of quicker and more efficient access to medicines for patients, with better use of staff skills, corresponded to the drivers for non-medical prescribing identified in policy literature at the time (DH, 2006).
Experiences of nurse prescribers
Three nurse prescribers from three clinical teams were interviewed twice for the study. The teams were selected for analysis because their ways of working were considered to exemplify new models of service provision.
The nurse prescribers interviewed said their prescribing practice had a positive impact on patient care and team working, and had enabled them to make better use of their nursing skills. The nurses felt confident prescribing and said this confidence had developed over time. The support they received from medical colleagues, nurse managers and peers was crucial to the successful implementation of their prescribing roles.
An action learning set was established at the study site with the aim of supporting novice nurse prescribers. All three nurse prescribers interviewed said this had helped improve their confidence and competence to practise.
Three doctors, three non-prescribing nurses and a pharmacist were also
interviewed for the study; all worked in the same teams as the nurse prescribers. They unanimously reported the benefits of the new prescribing roles on patient care and effective team working, with the role changes seen as a “natural progression” for the nurses involved.
Differences between medical and nurse prescribers
A null hypothesis that there are no differences between the roles of medical and nurse prescribers was investigated using a 15-item structured observation tool. This was designed to assess prescriber competence as well as ability to manage patients’ medicine needs (Latter et al, 2005).
A total of 52 patient prescriber consultations were observed with 47 patients attending hypertension and renal clinics. The prescribing practices of the two nurse prescribers and two medical prescribers observed were comparable across the dataset. No differences were found in the following:
- Length of consultation;
- Prescribers’ approach to patients;
- The ways in which medicines or follow-up consultations were managed;
- The number of patients who received a prescription;
- The medicines prescribed; or
- The frequency of prescribing by the prescriber.
While there were some differences in the method of prescriptions used, such as new or repeat medicines, the dataset was too small to test for their significance.
A 40-item patient survey was also conducted to investigate the null hypothesis. Purposive sampling was used to select 122 patients who attended the observed hypertension and renal clinics; the principal inclusion criteria were that the patients understood English and could complete the survey in English. The response
rate was 61%, with 74 patients returning completed questionnaires.
The survey included two validated rating scales that measured patients’ beliefs about their medicines and reported satisfaction with the information they received about medicines (Horne et al, 2001; 1999). No differences were found in patients’ beliefs about their medicines, but a statistically significant difference was found in their satisfaction with the information received about their medicines – patients who had consulted a nurse reported higher satisfaction ratings than those who had consulted a doctor. Patients across all ethnic groups surveyed reported similar views about their experiences of prescribing and about their medicines.
The study findings led to the development of a model illustrating what should be considered when implementing a role change. The model contained five forces and four factors (Box 1).
Box 1. Model for implementing role change
Forces required to implement and sustain new roles in practice
- Viewing workforce changes as an opportunity
- Improved patient care
- Effective sponsorship
- Team engagement
- Expert care
Factors crucial to the successful implementation of new prescribing roles
- Shared vision
- Local championship
- Action learning
- Team, peer and buddy support
This small study used a qualitative design underpinned by case study methodology to explore the implementation of nurse prescribing roles in an acute care setting. Its findings add to the growing body of evidence in support of nurse prescribing. It is now time to focus less on the variation of care delivered by different professional groups and more on the contribution nurses make towards improving outcomes and delivering safe and effective patient care. NT
This article is a summary of: Jones K et al (2011) Nurse prescribing roles in acute care: an evaluative case study. Journal of Advanced Nursing; 67: 1, 117-126.
Department of Health (2006) Medicines Matters. A Guide to Mechanisms for the Prescribing, Supply and Administration of Medicines. London: DH.
Department of Health (2002) Extending Independent Nurse Prescribing Within the NHS in England. A Guide forImplementation. London: DH.
Horne R et al (2001) Satisfaction with information about medicines scale (SIMS). Quality in Health Care; 10: 135-140.
Horne R et al (1999) The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychology and Health; 14: 1-24.
Latter S et al (2005) An Evaluation of Extended Formulary Independent Nurse Prescribing: Executive Summary of Final Report. Policy research programme at the Department of Health. Southampton: University of Southampton.
Latter S, Courtney M (2004) Effectiveness of nurse prescribing: a review of the literature. Journal of Clinical Nursing; 13: 1, 26-32.