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

Faculty of Health & Social Care Sciences, St. George's University of London & Kingston University, Grosvenor Wing, Cranmer Terrace, London, SW17 ORE, UK.
BMC Health Services Research (Impact Factor: 1.71). 12/2011; 11(1):330. DOI: 10.1186/1472-6963-11-330
Source: PubMed


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.
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.
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.
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.

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Available from: Sadiq Bhanbhro, Mar 18, 2014
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    • "However, there is scope for pharmacists to do more. Pharmacists in other countries, such as the UK, USA and Canada, have adopted expanded prescribing roles into their practice.10,11,12,13,14 Broadly, these models of prescribing are either independent or dependent (i.e. "
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    ABSTRACT: To explore the potential for community pharmacist prescribing in terms of usefulness, pharmacists' confidence, and appropriateness, in the context of asthma management. Twenty community pharmacists were recruited using convenience sampling from a group of trained practitioners who had already delivered asthma services. These pharmacists were asked to complete a scenario-based questionnaire (9 scenarios) modelled on information from real patients. Pharmacist interventions were independently reviewed and rated on their appropriateness according to the Respiratory Therapeutic Guidelines (TG) by three expert researchers. In seven of nine scenarios (78%), the most common prescribing intervention made by pharmacists agreed with TG recommendations. Although the prescribing intervention was appropriate in the majority of cases, the execution of such interventions was not in line with guidelines (i.e. dosage or frequency) in the majority of scenarios. Due to this, only 47% (76/162) of the interventions overall were considered appropriate. However, pharmacists were deemed to be often following common clinical practice for asthma prescribing. Therefore 81% (132/162) of prescribing interventions were consistent with clinical practice, which is often not guideline driven, indicating a need for specific training in prescribing according to guidelines. Pharmacists reported that they were confident in making prescribing interventions and that this would be very useful in their management of the patients in the scenarios. Community pharmacists may be able to prescribe asthma medications appropriately to help achieve good outcomes for their patients. However, further training in the guidelines for prescribing are required if pharmacists are to support asthma management in this way.
    03/2014; 12(1):390. DOI:10.4321/S1886-36552014000100009
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    • "A previous systematic review [51] and subsequent updating found no United Kingdom (UK) studies that reported from objective prescribing data by nurses in primary care (although as the review noted some studies may have included data from primary care but it was not possible to separate from that in hospital settings). This study addressed the following research questions: "
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    ABSTRACT: A growing number of countries legislate for nurses to have medication prescribing authority although it is a contested issue. The UK is one of these countries, giving authority to nurses with additional qualifications since 1992 and incrementally widened the scope of nurse prescribing, most recently in 2006. The policy intention for primary care was to improve efficiency in service delivery through flexibility between medical and nursing roles. The extent to which this has occurred is uncertain. This study investigated nurses prescribing activities, over time, in English primary care settings. A secondary data analysis of a national primary care prescription database 2006-2010 and National Health Service workforce database 2010 was undertaken. The numbers of nurses issuing more than one prescription annually in primary care rose from 13,391 in 2006 to 15,841 in 2010. This represented forty three percent of those with prescribing qualifications and authorisation from their employers. The number of items prescribed by nurses rose from 1.1% to 1.5% of total items prescribed in primary care. The greatest volume of items prescribed by independent nurse prescribers was in the category of penicillins, followed by dressings. However, the category where independent nurse prescribers contributed the largest proportion of all primary care prescriptions were emergency contraception (9.1%). In contrast, community practitioner nurse prescribers' greatest volume and contribution was in the category of among gel and colloid dressings (27%) , medicated stockings (14.5%) and incontinence appliances (4.2%). There were slightly higher rates of nurse prescribing in areas with higher levels of socio-economic deprivation and fewer physicians per capita, but the correlations were weak and warrant further investigation. The percentage of prescriptions written by nurses in primary care in England is very small in comparison to physicians. Our findings suggest that nurse prescribing is used where it is seen to have relative advantage by all stakeholders, in particular when it supports efficiency in nursing practice and also health promotion activities by nurses in general practice. It is in these areas that there appears to be flexibility in the prescribing role between nurses and general practitioners.
    BMC Health Services Research 02/2014; 14(1):54. DOI:10.1186/1472-6963-14-54 · 1.71 Impact Factor
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    • "NMP legislation exists in Cameroon, Zimbabwe, Rwanda, Swaziland, Malawi, Tanzania, Zambia, Ghana, Lesotho and Ethiopia*. * Adapted with permission from Bhanbhro et al (2011). ** Hahtela and Holopainen (2011). "
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    ABSTRACT: The massive scarcity of physicians in India, mainly in rural areas, prompted the Union Ministry of Health and Family Welfare to propose a three-and-a-half year Bachelor of Rural Health and Care degree designed exclusively to serve rural populations. The fierce opposition by powerful medical lobbies forced the proposal to fade away. This paper emphasises the importance of "task shifting" and "non-physician prescribing" in the global context and argues that non-physician healthcare providers would not only increase availability and accessibility to rural healthcare, but also provide an empowered second line of authority, adding to the checks and balances to the exploitative prestige-based hierarchy that pervades this knowledge-intensive service. T he world is facing severe shortage of healthcare profes-sionals on the face of the ever-increasing burden of non-communicable chronic morbidities. The World Health Organisation (WHO) estimates that 57 countries are experien-cing alarmingly low levels of trained health personnel. 1 While a few Asian countries have the required doctor-patient ratio per 1,000 (Japan 2.1, Korea 2, Singapore 1.8 and China 1.4), India has only 0.69 doctors/1,000. 2 WHO estimates that India cannot achieve the recommended target of "one doctor per 1,000 people" till 2028 (Sinha 2012a). India has two healthcare professionals per 1,000 people against the WHO's recommendation of 2.8/1,000. The fi gure drops to 1.4/1,000 on removing census errors from self-reporting of false qualifi cations. Lancet suggests that the Indian health force, if adjusted for qualifi cation gaps, may be only a quarter of WHO targets (Rao et al 2011). While India is short of six lakh doctors, 10 lakh nurses, and two lakh dental surgeons, 40,000 Indian doctors are serving 50% of the British population, and around 50,000 Indian doc-tors are working in the United States (US). About 20% and 10% doctors in Australia and Canada, respectively have received their MBBS degree from India. Reports suggest that 1,157 Indian doctors migrated abroad between April 2010 and March 2011 (Duttagupta 2012; Sinha 2012b). Mass migrations appear to be a problem shared by developing nations as a whole; for instance, WHO reports that 34% of Zimbabwean nurses and 29% of Ghana's physicians are working abroad (Hooper 2008). More importantly, rural India, with 70% of the population, has only 0.39 doctors/1,000 people against 1.33 for urban. Of the available 6,77,000 doctors, 70% work in urban health-settings (Rao et al 2011). This uneven rural-urban distribution is worsened by a "prestige-based hierarchy" in which physi-cians dominate and undermine the potential contributions from non-physician healthcare professionals.
    Economic and political weekly 03/2013; XLVIII(13):112-117.
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