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Issues affecting the growth of independent prescribing
Abstract
AIM: To investigate factors that have influenced A&E departments, minor injury units (MIUs) and walk-in centres (WICs) on whether or not to send nurse practitioners on extended nurse prescribing courses. Also, to examine the extent to which nurses who have completed an extended course are independently prescribing in their everyday practice. METHOD: A pilot study was undertaken in 20 randomly selected units, and following minor changes the main study was carried out by sending a questionnaire with a stamped addressed envelope to all nurse managers in 307 units. The response rate was 62 per cent (n=192). RESULTS: The study found that 71 per cent (n=20) of WICs, 30 per cent (n=33) of A&E departments and 20 per cent (n=11) of MIUs have sent nurses on extended nurse prescribing courses. The most striking result was that 44 per cent (n=28) of nurses were still not prescribing even after completing the course. Patient Group Directions (PGDs) are the most common method for nurse practitioners to obtain medication for patients and 81 per cent (n=52) of nurses who have completed the course would continue to work under PGDs to supplement the formulary. CONCLUSION: It was surprising and worrying to find that less than half (n=28, 44 per cent) of nurse prescribers do not prescribe after completing the course. The reasons for this are unclear but could include: inappropriate selection of staff and problems accessing prescription pads, lack of peer supervision and inadequate knowledge of pharmacology. More studies are needed to understand the reasons and to help ensure government targets on increasing the numbers of nurse prescribers are met.
... In order to improve safety, increased competency assessment and training was recommended (Baxter et al, 2002;Jones, 2002b;Larsen, 2004;Baileff, 2007), in conjunction with the development of national PGDs by the DH (Baxter et al, 2002). Methods of competency assessment found to be effective included knowledge assessment via questionnaire (Brooks et al, 2003) and role play (Bacon et al, 2003). ...
... PGDs were the most commonly used method of medicine supply used by nurse practitioners in secondary care, owing to the wide range of medicines available compared with the Nurse Prescribers' Formulary (Larsen, 2004). Only a minimal number of patients surveyed in a sexual health clinic would have preferred to have been seen by a doctor (Handy, 2002). ...
... It was perhaps surprising that the cost of development of PGDs was cited as a restraining factor to implementation (Hippisley-Cox et al, 2003;Larsen, 2004), given that an anticipated benefit of their introduction was cost effective prescribing (National Prescribing Centre, 2009). The criticism expressed regarding the lack of guidance to standardize quality, may have been addressed by the implementation of DH PGD templates (National electronic Library for Medicines, 2010), although standardization of PGDs is not universally supported. ...
Patient Group Directions (PGDs) have been used in clinical practice for a decade. They enable non-medical practitioners to supply medicines to patients, in certain legally defined circumstances, without a doctor's prescription and in accordance with a pre-defined protocol. The authors aimed to review the existing literature in order to identify and evaluate the evidence regarding the quality, safety and acceptability of PGDs within care systems and their impact on health outcomes. Searches of relevant databases were conducted, articles screened against eligibility criteria and relevant data extracted. A number of key issues emerged from the data including quality and safety of practice, acceptability to patients and practitioners, access to treatment and implications for professional roles and responsibilities. There were no data related to health outcomes. The review concludes that while PGDs may be an acceptable way to deliver care, their impact on patient outcomes and health status has been poorly studied.
... Two studies (Larsen, 2004;Latter et al., 2005) have examined the prescribing patterns of independent extended nurse prescribers. In line with the low prescribing rates of DN/HV prescribers, Larsen (2004) in a survey of 307 nurse managers (working in accident and emergency departments, minor injury units and walk-in-centres) reports that only 27 out of 55 nurses who had undergone prescribing training were prescribing medicines. ...
... Two studies (Larsen, 2004;Latter et al., 2005) have examined the prescribing patterns of independent extended nurse prescribers. In line with the low prescribing rates of DN/HV prescribers, Larsen (2004) in a survey of 307 nurse managers (working in accident and emergency departments, minor injury units and walk-in-centres) reports that only 27 out of 55 nurses who had undergone prescribing training were prescribing medicines. In contrast, Latter et al. (2005) examining the prescribing patterns of independent extended nurse prescribers, reported that over 90% of the 246 independent extended nurse prescribers surveyed used extended prescribing. ...
... One consistent finding related to independent prescribing that has clearly influenced prescribing rates is the limited choice of medicines available to nurse prescribers (Latter et al., 2005;Larsen, 2004;While and Biggs, 2004;Lewis-Evans and Jester, 2004;Otway, 2002;Luker et al., 1997Luker et al., , 1998, nurses claiming that they are unable to prescribe treatments that they consider essential to their nursing practice. ...
Nurses are able to prescribe independently from a list of nearly 250 prescription only medicines for a range of over 100 medical conditions or, from the whole British National Formulary as a supplementary prescriber. There is some evidence available on the prescribing practices of district nurses and health visitors and early independent extended prescribers. Little or no attention has focussed on supplementary nurse prescribing.
To provide an overview of the prescribing practices of independent extended/supplementary nurse prescribers and the factors that facilitate or inhibit prescribing.
National questionnaire survey.
United Kingdom.
A convenience sample of 868 qualified independent extended/supplementary nurse prescribers self-completed a written questionnaire.
A total of 756 (87%) used independent extended prescribing; 304 (35%) used supplementary prescribing to treat a range of chronic conditions (including asthma, diabetes and hypertension); 710 (82%) nurses worked in primary care. Nurses in general practice reported the largest number of reasons preventing prescribing. Reasons included the inability to computer generate prescriptions and to implement the Clinical Management Plan. Nurses in primary care reported more continuing professional development needs. These needs included update on prescribing policy and the treatment management of conditions. A total of 277 (32%) nurses were unable to access continuing professional development.
Independent extended/supplementary nurse prescribers work predominantly in primary care and do prescribe medicines. These nurses are highly qualified and have many years clinical experience. Supplementary prescribing is used by a minority of nurses. Implementing the Clinical Management Plan is a barrier preventing the use of this mode of prescribing. The continuing professional development needs of independent extended/supplementary nurse prescribers are frequently unmet. It will become increasingly important that these needs are met once nurses are able to prescribe the full range of medicines included in the British National Formulary, limited only by their area of competence.
... Several studies (Larsen 2004, Latter et al. 2005) have reported on the prescribing rates of independent extended nurse prescribers. In line with the low prescribing rates of DN/HV prescribers, Larsen (2004) surveyed 307 nurse managers working in minor injury units, accident and emergency departments and walk-in-centres, and reported that only 27 out of 55 nurses who had qualified as independent extended prescribers were prescribing medicines. ...
... Several studies (Larsen 2004, Latter et al. 2005) have reported on the prescribing rates of independent extended nurse prescribers. In line with the low prescribing rates of DN/HV prescribers, Larsen (2004) surveyed 307 nurse managers working in minor injury units, accident and emergency departments and walk-in-centres, and reported that only 27 out of 55 nurses who had qualified as independent extended prescribers were prescribing medicines. In contrast, Latter et al. (2005) reported that over 90% of the 246 independent extended nurse prescribers they surveyed (the majority of who worked in general practice in primary care) used independent extended prescribing. ...
... The limited choice of medicines is one factor that has been reported by several researchers as influencing prescribing rates (Latter et al. 2005, Larsen 2004, While & Biggs 2004, nurses claiming that they are unable to prescribe treatments that they consider essential to their nursing practice. ...
This paper is a report of a survey to provide an overview of nurse independent prescribing and nurse supplementary prescribing across the United Kingdom.
Evidence examining the frequency of prescribing by nurses is conflicting, and it is evident that several factors hamper prescribing practice. As of May 2006, legislative changes gave appropriately qualified nurses virtually the same independent prescribing right as doctors. However, there is currently no evidence available about the prescribing practices of these nurses.
A random sample of 1992 qualified Nurse Independent/Nurse Supplementary Prescribers registered with the Nursing and Midwifery Council was sent a postal questionnaire in 2006. A total of 1400 (70%) questionnaires were returned, of which 1377 were completed.
Eight hundred and ninety-one (65%) respondents worked in primary care, and 333 (24.3%) worked in secondary care. Three quarters of the sample had more than 5-year clinical experience in the area in which they prescribed prior to entering the prescribing programme. One thousand one hundred and seven (87%) participants had used nurse independent prescribing and 568 (44.6%) nurse supplementary prescribing. Restriction of local arrangements, implementation of the Clinical Management Plan and access to doctors hampered or prevented prescribing.
The adoption of prescribing by nurses in the United Kingdom has increased patient choice with regard to access to medicines. A number of factors which hamper or prevent prescribing require further exploration.
... Three studies (Larsen 2004, Latter et al. 2005) have examined the prescribing patterns of independent extended nurse prescribers. In line with the low prescribing rates of DN/HV prescribers, Larsen (2004) in a survey of 307 nurse managers (working in accident and emergency departments, minor injury units and walk-incentres) reports that only 27 of 55 nurses who had undergone independent extended prescribing training were prescribing medicines. ...
... Three studies (Larsen 2004, Latter et al. 2005) have examined the prescribing patterns of independent extended nurse prescribers. In line with the low prescribing rates of DN/HV prescribers, Larsen (2004) in a survey of 307 nurse managers (working in accident and emergency departments, minor injury units and walk-incentres) reports that only 27 of 55 nurses who had undergone independent extended prescribing training were prescribing medicines. ...
To examine the prescribing practices of nurse supplementary prescribing in diabetes.
Nurses in several roles are involved in the management of medicines for patients with diabetes. Nurse prescribing should help optimise these roles. Nurses in the UK have virtually the same independent prescribing rights as doctors. There is little or no evidence on the extent to which nurse supplementary prescribing is used, or the impact and activity of nurse supplementary prescribing for patients with diabetes.
Survey.
A random sample of 214 nurse supplementary prescribers self-completed a written questionnaire.
The majority of nurses held an academic qualification at degree level or higher, had a wealth of clinical experience, worked full-time, were based in primary care and worked in general practice. The majority of nurses prescribed between one and five items a week. Oral anti-diabetic drugs, hypertension and lipid-regulating drugs and insulins were the products most often prescribed. Over 85% had undertaken specialist training in diabetes prior to undertaking the prescribing programme.
Supplementary prescribing provides a practical and useful framework within which to prescribe medicines for patients with diabetes and its associated complications. Specialist diabetes training is a necessary prerequisite for nurses prescribing in this area. It is evident that there is still a place for supplementary prescribing.
* Recent legislative changes mean that nurses can now independently prescribe practically any drug. * Nurses in general practice appear to prescribe most frequently as a nurse supplementary prescriber for patients with diabetes. * Nurse supplementary prescribers are likely to use this mode of prescribing to deliver medicines to patients with diabetes. * Over two-thirds prescribe for common but serious complications of diabetes, e.g. hypertension, hyperlipidaemia and cardiovascular disease.
... Despite the Review of Prescribing, Supply and Administration of Medicines and the introduction of non-medical prescribing (Department of Health, 1999), several studies have identified that nurses are still not prescribing following successful attainment of their non-medical prescribing qualifications (While and Biggs, 2004;Larsen, 2004). A recent mixed methods study identified a range of factors that can influence non-medical prescribing such as: lack of peer clinical supervision, inadequate knowledge of pharmacology, lack of diagnostic reasoning, limited formulary and variations in prescribing practices among individual Doctors, reticence to challenge treatments already initiated by another team member, fear of prescribing for patients with multiple co-morbidities, polypharmacy and information from pharmaceutical companies (Latter et al., 2010;While and Biggs, 2004). ...
There are approximately 54 000 nurse and midwife prescribers across the United Kingdom (UK), with 19 000 nurse independent and supplementary prescribers. Prostate cancer specialist nurses are ideally suited to implement advanced levels of practice in non‐medical prescribing, but little has been detailed in the literature about the prescribing practice in this clinical context. This paper set out to critically review evidence‐based recommendations for Prostate Cancer Specialist Nurses using a case study reflection to contextualize the role of non‐medical prescribing.
A structured literature review was conducted in a range of electronic databases ( DARE , Cochrane, MEDLINE , BNI , PsychINFO , EMBASE and CIHAHL ), and a grey literature search in google, to identify studies employing a qualitative and/or quantitative methods. National (UK) and European clinical guidelines and legislative frameworks were also included. Methodological evaluation was conducted and evidence‐based recommendations were integrated into a narrative synthesis.
A multidisciplinary and proactive approach to the management of men with metastatic prostate cancer ensures safe and effective prescribing practice, and optimizes supportive care delivery. A reflective case study has illuminated the key features necessary to maximize the success of non‐medical prescribing in prostate cancer care and captures the importance of good working relationships. While different practice models will emerge, the Prostate Cancer Model of Consultation may facilitate a structured framework for safe practice, embedded in effective communication strategies.
Non‐medical prescribers must be committed to continual professional development, and prescribe safely within individual competencies and scope of professional practice. There is a pressing need for further research to evaluate prescribing practices with a particular focus on the nature of influencing factors on prescribing decisions, cost‐effectiveness and a more detailed understanding of how team working and inter‐team referral affects prescribing decisions between the Multidisciplinary Team (MDT) members.
... 11 Practice level ■ Concern among doctors regarding an erosion of their professional status, 3,12 insufficient training and lack of funding for nurse prescribing 12,13 ■ Issues among doctors regarding remuneration for mentoring nurses during training, similar to that received when teaching medical students. 4,14 Individual level ■ Isolation, lack of support and inadequate clinical supervision among nurse prescribers 7,15,16 ■ Under-confidence among nurses 13,17 ■ Age factors -disparities in continuing professional development (CPD), 18 with variable opportunities that are not geared to the particular needs of older nurses. 19 Aims of the project The aims of this project were to identify: ■ The number of practice nurses in one county qualified as nurse prescribers, extended or supplementary prescribers or who wished to gain this qualification ■ The number of practice nurses qualified and working as nurse practitioners and nurses who provide first-contact care for minor illnesses ■ The number of practice nurses involved in the management of chronic diseases ■ Barriers that may exist among practice nurses to pursuing the NIP qualification. ...
Practice nurses are defined as those nurses who work in general practices and are employed by GPs.This includes nurses who have gained further qualifications and are working as nurse practitioners and minor illness specialist nurses. Despite the success of nurse-led services in primary care, the move into extended nurse prescribing has not been as high as predicted. A questionnaire survey of all 251 practice nurses in one southern English county was conducted in order to ascertain current roles and responsibilities, prescribing qualifications (both actual and planned), and perceived barriers to acquiring a nurse independent prescriber qualification. The findings identified what local practice nurses perceive to be barriers to nurse prescribing with issues of age, salary, support and training all playing a part in discouraging the uptake of this qualification.
... Indeed Eraut et al. (1995) and Clark (1995) have commented that as practice becomes more complex the need for nurses to understand and apply their knowledge in the clinical area increases. However studies continue to provide evidence that nursing students commonly acknowledge problems in learning biological sciences (McKee, 2002;Dorthe, 2004;King, 2004;Fleming and McKee, 2005). Traditionally this subject has been taught using key lectures followed by small group tutorials however both the student population and the resources available to lecturers have changed dramatically with the development of information and communication technology (ICT) in higher education. ...
Nurses require an understanding of pathophysiological processes to support safe practice in the clinical area. A review of the literature indicates that nursing students have traditionally found this to be a challenging element of the course. The increasing availability of newer technology in higher education such as videostreaming and podcasting provides the opportunity to utilise a variety of approaches to cater for a wider range of learning styles. In view of this, lecturers developed multimedia resources to incorporate into a pathophysiology module. An evaluation of students' views on the use of ICT to facilitate understanding of pathophysiology was undertaken. The majority of students appeared to welcome the incorporation of alternative teaching approaches into the module. Interestingly despite the opportunities which technology offers to enhance learning many of the students also highlighted the importance of maintaining significant face-to-face contact with lecturers. This supports the findings of the literature which indicates that students find hybrid learning strategies that combine traditional teaching with more innovative methods particularly beneficial.
... Several recent studies have found barriers to effective nurse prescribing. 29,[53][54][55] Some nurses are reported to be 'reverting back' to pre-nurse prescribing practices asking doctors to countersign prescription requests or asking patients to attend the general practice to obtain a prescription. 53 Among the contributing factors identified were a lack of appropriate supportive infrastructures, cumbersome administrative processes and difficulties with ongoing medical supervision. ...
Non-medical nurse prescribing in the UK continues to evolve with new legislative frameworks. Studies evaluating patterns of prescribing by nurses remain scarce. This secondary data analysis of national prescribing data investigated the prescribing behaviours of community-based nurses and general practitioners (GPs), using constipation as a case study. Currently, 37 683 registered nurses, midwives and health visitors are qualified to independently prescribe in the UK; however, only 16.6% of nurses prescribed items for constipation. Prescribing practices differed between nurses employed by primary care trusts (PCTs) and general practice, between nurses and GPs, and across regions. PCT-employed nurses undertook 83% of nurse prescribing although activity increased steadily among general practice-employed nurses. Pharmacological treatment choices differed between nurses and GPs. Over 60% of all nurses predominantly prescribed from one class of laxative compared with a wider range prescribed by GPs. The extent, impact and outcomes of medical prescribing need further study.
Patient group directions (PGDs) allow the administration of medicines to groups of patients who fit specific criteria, without having to write an individual prescription for each patient. The use of PGDs in stoma carenursing practice can significantly improve patients' quality of life, increase autonomy and accountability for the clinical nurse specialist, and provide a credible alternative to independent nurse prescribing. Julie Burton outlines the use of PGDs in stoma care nursing, and documents their introduction in one stoma care department.
Professor Molly Courtenay discusses the benefits and factors which inhibit and facilitate nurse prescribing practice.
Recommendations were first made in 1986 for nurses to take on the role of prescribing (Department of Health [DoH], 1986). Eight years later (although limited to district nurses and health visitors), nurses in eight demonstration sites throughout England began to independently prescribe (Morris, 1994). There are now approximately 29000 district nurses and health visitors (DoH, 2005a) qualified to prescribe from the list of appliances, dressings, Pharmacy, General Sales List items, and 13 Prescription Only Medicines included in the Nurse Prescribers' Formulary for Community Practitioners (British Medical Association and Royal Pharmaceutical Society of Great Britain, 2006). This article explores recent advances that have further increased the prescribing power of nurses, namely nurse independent prescribing and nurse supplementary prescribing.
This article discusses the challenging question of facilitating the educational requirements of students who enter the extended/supplementary prescribing programmes from diverse clinical backgrounds. Data emerging from a survey of mental health nurses (MHNs) by one of the authors (S.H.) and specifically what they perceive as the educational providers role in helping them develop as prescribers is presented. Secondly, the second author (J.D.) then discusses the implications of responding to student's expectations and importantly facilitating competence for the student for the differing contexts of where they will prescribe.
Purpose: The purpose of this study was to examine current nurse practitioner (NP) curricula in the United States with regard to antibiotics and antimicrobial resistance and assess the need for a web-based module for instruction on antimicrobial resistance and appropriate prescribing of antibiotics.
Data sources: A 22-item, anonymous, self-administered, web-based survey was sent to 312 NP programs; 149 (48%) responded. Survey items included questions related to NP specialties offered, program accreditation, format of pharmacology course(s), lecture hours related to antimicrobial therapy, and whether the participant would use a Web-based module to teach NP students about antimicrobial resistance, if one were available.
Conclusions: Most NP programs (99.3%) required a pharmacology course, and 95% had lectures dedicated to antimicrobial therapy. Half of the programs (53.5%) devoted ≥4 lecture hours to antimicrobial therapy in the pharmacology course, and most (84.8%) reported covering antimicrobial therapy in nonpharmacology courses as well. Approximately half of the programs (45.3%) reported <4 h of lecture on antimicrobial therapy in nonpharmacology courses. Many programs (51.9%) did not offer a microbiology course; 39.2% required microbiology as a prerequisite. Most respondents (86.7%) were familiar with the Centers for Disease Control and Prevention antimicrobial resistance program, and 92.6% reported that they would use an electronic module regarding resistance.
Implications for practice: NP curricula generally include <10 h of content on antimicrobial therapy. An electronic module regarding antimicrobial resistance is likely to be a useful and relevant adjunct to current curricula.
Nurse prescribing has been established in the UK since 1994, however, limited focus has been placed on the experiences of district nurses adopting this additional role. This phenomenological study explores the experiences of district nurses prescribing as nurse independent prescribers across the West of Scotland. A qualitative Heideggarian approach examined the every-day experiences of independent prescribing among district nurses. A purposive sample was used and data collected using audio taped one-to-one informal interviews. The data was analysed thematically using Colaizzi's seven procedural steps. Overall these nurses reported that nurse prescribing was a predominantly positive experience. Participants identified improvements in patient care, job satisfaction, level of autonomy and role development. However, some of the participants indicated that issues such as support, record keeping, confidence and ongoing education are all major influences on prescribing practices.
Nurses in the UK are now one group of non-medical staff who can prescribe. This practice is evolving for critical care nursing staff who care for critically ill patients during their stay in hospital through ward and outpatient follow-up after admission to critical care.
The purposes of this paper were to present existing information regarding prescribing to support nurses in critical care currently prescribing and to inform those who are intending to prescribe.
To develop the position statement, a search of the literature was conducted using key databases. To ascertain the current level and type of prescribing in critical care, a short questionnaire was sent by email to British Association of Critical Care Nursing members, and the results of this are presented in Appendix A. OUTCOMES/RESULTS: Evidence was found in relation to the history, context in critical care, educational requirements and issues of consent related to non-medical prescribing.
The position statement is based upon evidence from the literature, National Health Service policy and the Nursing and Midwifery Council regulations. It takes account of the critical care patient pathway before, during and after an admission to critical care.
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