Nurse prescribing: Reflections on safety in practice

Physicians' attitudes towards the development of the nurse prescribing role in critical care and emergency departments

BACKGROUND

The progression of the nurse prescribing role encounters numerous challenges, with physician resistance being a significant obstacle. This study aims to assess physicians' perspectives regarding the expansion of the nurse prescribing role within critical care and emergency departments.

METHODS

This cross-sectional study employed convenience sampling to enroll 193 physicians. Data collection instruments included a demographic information form and a researcher-developed questionnaire. Descriptive and inferential statistics were used to analyze the data using SPSS-22 software.

RESULTS

A total of 193 physicians participated in the survey, with a mean age of 41.9 ± 10.7 years. Among physicians from various age groups, genders, educational backgrounds, and clinical experiences, more than 60% acknowledged prescribing medicine as an essential component of their professional responsibilities. However, a significant majority of physicians in these categories agreed that in emergency situations, nurses should be allowed to prescribe medication to save patients' lives. It is worth noting that, unlike specialist and fellowship physicians, a majority of general practitioners (83.3%) held the view that nurse-prescribed medications do not contribute to the professional development of nursing. The nurse prescribing role encountered several predominant obstacles, namely legal consequences (78.8%), interference of duties between physicians and nurses (74.1%), and a legal vacuum (77.2%).

CONCLUSION

The majority of physicians expressed a favorable attitude towards nurse prescribing in emergency and critical care departments. To facilitate the development of the nurse prescribing role, it is essential to ensure the acquisition of scientific qualifications and implement necessary changes in nursing curricula across bachelor's, master's, and doctoral programs.

Developing a competence framework for nurses in pharmaceutical care: A Delphi study

BACKGROUND

Nurses play an important role in pharmaceutical care. They are involved in: detecting clinical change; communicating/discussing pharmacotherapy with patients, their advocates, and other healthcare professionals; proposing and implementing medication-related interventions; and ensuring follow-up of patients and medication regimens. To date, a framework of nurses' competences on knowledge, skills, and attitudes as to interprofessional pharmaceutical care tasks is missing.

OBJECTIVES

To reach agreement with experts about nurses' competences for tasks in interprofessional pharmaceutical care.

METHODS

A two-phase study starting with a scoping review followed by five Delphi rounds was performed. Competences extracted from the literature were assessed by an expert panel on relevance by using the RAND/UCLA method. The experts (n = 22) involved were healthcare professionals, nurse researchers, and educators from 14 European countries with a specific interest in nurses' roles in interprofessional pharmaceutical care. Descriptive statistics supported the data analysis.

RESULTS

The expert panel reached consensus on the relevance of 60 competences for 22 nursing tasks. Forty-one competences were related to 15 generic nursing tasks and 33 competences were related to seven specific nursing tasks.

CONCLUSIONS

This study resulted in a competence framework for competency-based nurse education. Future research should focus on imbedding these competences in nurse education. A structured instrument should be developed to assess students' readiness to achieve competence in interprofessional pharmaceutical care in clinical practice.

Time for change? A qualitative exploration of the educational preparation and subsequent continuing professional development needs of nurse and midwife prescribers

AIM/OBJECTIVE

The aim of this study was to explore nurse and midwife prescribers' perception of their educational preparation for the role and identify continuing professional development (CPD) requirements to generate practitioner-based knowledge with the potential to inform education and research, policy and practice.

BACKGROUND

Educational preparation for the nurse and midwife prescribing role has remained relatively unchanged since its introduction and follows a model whereby practitioners engage in theoretical learning and learning situated within the clinical environment, facilitated by a dedicated medical mentor. No significant examination of this preparation has been undertaken in Ireland since 2009.

DESIGN

This was a qualitative study, guided by elements associated with hermeneutic phenomenology.

METHODS

Following research ethics approval and informed consent, 16 participants from 2 maternity hospitals participated in one-to-one audio recorded semi-structured interviews.

RESULTS

Participants experience of the education programme varied with some acknowledging the importance of a broad pharmacological module whereas others believed it to be irrelevant given their prescribing scope was in many instances quiet narrow. The experience of being mentored by a medical doctor ranged from a positive learning experience to one which did not contribute to learning. Barriers to engaging with CPD were identified along with advancements in the practice arena which identify additional CPD requirements.

CONCLUSIONS

This study has generated practitioner-based knowledge which provides direction for future developments in the educational preparation of nurse and midwife prescribers, particularly around pharmacology and mentorship and outlines specific CPD requirements for practitioners.

Gastroenterology nurse prescribing in China: A Delphi method

AIM

This study aims to identify and reach a consensus among experts on the specific gastroenterology drugs that a gastroenterology nurse may be able to prescribe.

DESIGN

This study employs a modified Delphi design to reach a consensus among medical and nursing experts about the gastroenterology system drugs that nurses may prescribe medication.

METHOD

From August 2019-November 2019, a two-round study, consisting of 26 medical and nursing experts, was conducted using the Delphi method. IBM SPSS Ver. 22 and descriptive statistical software were used to analyse the results of the consultations.

RESULTS

A total of 37 drugs across nine categories are identified as relevant to Chinese nurses working in gastroenterology departments. Among them, four drugs are generally prescribed independently, 24 tend to be prescribed collaboratively and nine are prescribed either independently, or in collaboration with others.

CONCLUSIONS

This list is a fundamental and dependable instrument for identifying the gastroenterology drugs that could possibly be prescribed by gastroenterology nurses in China. The research results have important guiding significance for the formulation and implementation of relevant policies for nurses to prescribe medicines.

IMPACT

Nurse prescribing has become a global trend and is slowly gaining attention in China under the development strategy of 'Healthy China'. As such, this list will give some reference for policy formulation and implementation of future nurse prescribing in mainland China.

Prescription for care

Nursing and midwifery practice has evolved, with many nurses and midwives now holding prescriptive authority. This paper reports on findings in relation to care which formed part of a broader qualitative study which aimed to explore the experiences of nurse and midwife prescribers in the maternity setting in Ireland. Following research ethics approval, 16 nurse/midwife prescribers participated in one-to-one audio recorded semi-structured interviews. Prescriptive authority both enhances the caring role of the nurse/midwife and supports safer care. The ways in which this happened have been illuminated though barriers have also been identified. In order for the full potential of nurses/midwives with prescriptive authority to be realised, measures such as increasing the number of prescribers and the provision on non-interruption zones need to be considered.

A comparison between independent nurse prescribing and patient group directions in the safety and appropriateness of medication provision in United Kingdom sexual health services: A mixed methods study

BACKGROUND

United Kingdom legislation allows nurses to autonomously provide medications as independent nurse prescribers or using patient group directions. Evidence of medication safety and appropriateness is limited. We compared nurse prescribers and patient group direction users in terms of prevalence, types and severity of medication provision errors.

METHODS

Objectives: Compare safety and appropriateness of medication provision between nurse prescribers and patient group direction users.

DESIGN

MIXED METHODS: clinical notes review and nurse-patient consultation observations.

SETTING

Five United Kingdom sexual health services.

SELECTION CRITERIA

'Clinical notes review' included a random selection of nurse-patient consultations July-December 2015, 743 consultations managed by nurse prescribers and 939 consultations by patient group direction users. 'Observation study' involved 15 nurse prescriber and 15 patient group direction user nurse-patient medication consultations. Patients aged under 16 or non-English speaking were excluded.

MEASUREMENTS

Medication safety/appropriateness was compared between nurse prescribers and patient group direction users. Medication provision errors were categorised and assigned severity ratings. The Medication Appropriateness Index and the Prescribing Framework were used to assess medication provision.

RESULTS

Of 1682 clinical notes (nurse prescribers=743, 44%; patient group directions=939, 56%), 879 involved the provision of 1357 medications (nurse prescribers=399, 54%; patient group directions=480, 51%). The overall error rate was 8.5% (1844 errors from a potential 21,738 errors), predominantly related to documentation omissions. Nurse prescribers were more likely to make an error compared to patient group directions users (error rates 9% versus 8%, respectively; p=0.001); most were 'minor' (nurse prescribers=489, 56%; patient group directions=602, 62%). Both nurse prescribers and patient group direction users made safe medication decisions (n=1640 of 1682 patient care episodes, 98%); however, patient group directions users worked outside patient group directions restrictions in 39 (8%) of consultations. In 101 consultations, medication was indicated but not documented as offered/provided. From 30 observed consultations assessed against the Prescribing Framework, nurse prescribers' and patient group directions users' clinical practice were comparable (maximum score 46: nurse prescribers=44.7; patient group direction=45.4, p=0.41).

CONCLUSION

Sexual health nurse prescribers and patient group direction users provided safe and therapeutically appropriate medication. Improvements in clinical documentation are recommended. Moreover, patient group directions users should be encouraged to adhere to patient group directions' governance restrictions, such as through regular training, audits and staff updates.

Embedding knowledge into non-medical prescribing education

This article focuses on the non-medical prescribing (NMP) module for community prescribers in a nurse education context. The module mainly attracts registered nurses (RNs) from community settings (such as health visiting, school nursing, district nursing and practice nursing), and is provided in higher education institutions (HEIs) as part of a specialist programme or a continuing workforce development module. The article discusses changes to the way the module was taught that can enhance student learning within the NMP module and facilitate wider success and confidence among community nurse prescribers. The move from Nursing and Midwifery Council standards for prescribing to a single competency framework from the Royal Pharmaceutical Society (RPS) has encouraged academics to revisit teaching strategies and consider an approach that offers wider student participation in learning. The use of technology-enhanced learning (TEL) in HEIs is part of national recommendations to improve the student experience and increase success.

Evaluation of safety standards accomplishment in educational hospitals of Neyshabur University of Medical Sciences-Iran

Patient's safety and staff in hospital is one issue that has always been considered as an important principle by experts in health systems. Therefore, for increase safety, standards and safety regulations must be considered. This study aims to evaluation of safety standards accomplishment in educational hospitals of Neyshabur University of medical Sciences. This cross-sectional descriptive study, safety standard status of all wards including 17 various wards from 22 Bahman hospital and 14 various wards from hakim Hospital in Neyshabur city (2016) was investigated. Data were collected using a questionnaire safety standard status hospitals (264 questions). Also data analyzed by SPSS16 software, using descriptive (Mean ± SD) and inferential statistics (T-Test). The results revealed that Safety standard status in 22bahman and hakim hospital were weak (2.42 ± 0.14) and moderate (3.04 ± 0.18) respectively. Also result showed in Hakim hospital, the highest and lowest safety standard status in Internal and Administrative-financial unit was (3.42 ± 0.19) (1.36 ± 0.58) respectively. In addition in hakim hospital, the highest and lowest safety standard status in operation room and administrative-financial unit (3.53 ± 0.28), 1.36 ± 0.58) respectively. According to the result, the safety condition in hospitals of Neyshabur city is moderate and poor status. However, imperfect implementation of safety protocols can endanger safety conditions in hospital. Therefore, it is necessary to take the required correcting measures to ensure full safety in hospitals. •Safety is defined by development of systems for preventing incidents, injuries, and other unpleasant events in organizations.•This article showed the safety status is not appropriate in most units of hospitals, which can lead to dangers for patients and personnel.•It is suggested for future studies to compare the safety status of different provinces.

Successfully developing advanced practitioner roles: policy and practice mechanisms

PURPOSE

The purpose of this paper is to lay out how advanced practitioner development occurs in New Zealand primary health care settings. The paper specifically focuses on mechanisms occurring across policy creation and in practice leading to successful role development.

DESIGN/METHODOLOGY/APPROACH

The authors applied a realist approach involving interviews, document review and field log observations to create refined theories explaining how successful development occurs.

FINDINGS

Three final mechanisms were found to influence successful advanced practitioner role development: engagement in planning and integrating roles; establishing opportunities as part of a well-defined career pathway; and championing role uptake and work to full scopes of practice.

RESEARCH LIMITATIONS/IMPLICATIONS

This research focuses on one snapshot in time only; it illustrates the importance of actively managing health workforce change. Future investigations should involve the continued and systematic evaluation of advanced practitioner development.

PRACTICAL IMPLICATIONS

The successful development of advanced practitioner roles in a complex system necessitates recognising how to trigger mechanisms occurring at times well beyond their introduction.

SOCIAL IMPLICATIONS

Potential candidates for new roles should expect roadblocks in their development journey. Successfully situating these roles into practice through having a sustainable and stable workforce supply provides patients with access to a wider range of services.

ORIGINALITY/VALUE

This is the first time a realist evaluation has been undertaken, in New Zealand, of similar programmes operating across multiple sites. The paper brings insights into the process of developing new health programmes within an already established system.

Nurse prescribing in primary care: a metasynthesis of the literature

Aim The aim of this metasynthesis was to develop an understanding of the existing theoretical perspectives around nurse prescribing and to identify any gaps in knowledge, which would support further research into the lived experience of the nurse prescriber in the primary care setting.

BACKGROUND

Nurse prescribing has been the focus of many research studies since its introduction, with many benefits to the patient, the prescriber and service identified; however, there remains variation in the utilisation of the prescribing qualification, particularly in primary care settings. Although a range of quantitative and qualitative studies have been undertaken, which aimed to explore the influences on prescribing, few have used a research methodology that supports the in-depth exploration of the nurse prescriber's experience.

METHODS

An extensive literature search was undertaken in April 2015 (20-24), which included UK and non-UK studies since 1999. Inclusion and exclusion criteria were applied to search for studies in which participants included nurse prescribers who practiced in primary or community care settings. Studies that only used a quantitative methodology and those not available in English were excluded. The literature search yielded 124 papers, with 50 papers remaining after the initial screen of full papers against the inclusion/exclusion criteria. The papers were reviewed and graded for their quality, with a further 13 papers excluded. A three-step qualitative analysis technique of metasynthesis was applied to the remaining 37 papers. Identification of similarities and differences enabled first-order interpretations to be identified, which were grouped into broader themes (second-order interpretations) by identifying concepts that applied to two or more studies. Further interpretation through synthesis of translation enabled third-order interpretations to emerge. Findings From the metasynthesis of the 37 papers, nine themes emerged: patient-centred care; benefits to the service; the need for knowledge; professional accountability and boundary setting; safety consciousness; barriers to effective prescribing; role preservation; power-shifts and inter-professional relationships; and culture of prescribing.

The views of non-medical prescribing students and medical mentors on interprofessional competency assessment - A qualitative exploration

BACKGROUND

The United Kingdom (UK) is one of the least restrictive countries in terms of scope of prescribing practice for non-medical prescribers and is a rapidly expanding group of professionals. In the United Kingdom nurse prescribers are assessed in practice by Designated Medical Practitioners (DMP) (doctors) which is a unique approach. In light of proposals to permit nurses to assess each other the benefits and challenges associated with current approach to interprofessional assessment warranted further exploration.

OBJECTIVE

The aim was to explore interprofessional competency assessment with nurse non-medical prescribing students and their DMPs.

DESIGN

A descriptive qualitative research design was undertaken using semi-structured interviews and focus groups.

SETTING

The study was completed in a Scottish University that provides non-medical prescribing education to nurses, midwives and allied health professionals.

PARTICIPANTS AND METHODS

Students (n=6) participated in two focus groups at the start and end of their supervised learning and assessment in practice. DMPs (n=6) participated in semi structured telephone interviews on completion of supervision. Utilising Clark's theory of interprofessional education, a thematic analysis was conducted.

FINDINGS

Professional identity influenced interpretation of prescribing competence with regards assessment and scope of practice. Students and DMPs learned with, from and about each other, and provided a platform for two-way learning and mutual professional respect. The interprofessional learning experience developed relationships and provided ratification for the prescribing role post qualification.

CONCLUSIONS

Further exploration with key stakeholders and service users is recommended, prior to any changes to the designated professional group assigned to assessing non-medical prescribing competence.

National survey of nurse prescribing in mental health services; a follow-up 6 years on

WHAT IS KNOWN ON THE SUBJECT?: Nurse prescribing allows nurses, after specific training, to prescribe medications under certain conditions. This article describes the third in a series of surveys of mental health services in England to understand how nurse prescribing is being used across the country. While there is research evidence that shows nurse prescribing to be as safe as prescribing by doctors and that service users typically find it at least as acceptable, there is a lack of detailed evidence about current forms of nurse prescribing practice specifically in mental health services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The survey found that the number of nurse prescribers has increased over the last few years. Nurse prescribers are increasingly prescribing in a form ('independent prescribing') that makes them independently responsible for prescribing decisions without working to a plan laid out by a doctor. Mental health organisations are increasingly planning in a systematic way how to identify, train and ensure good practice in nurse prescribing. This study demonstrates that growth in numbers of nurse prescribers can take place over an extended time period. The study demonstrates that the exact model of nurse prescribing will influence its applicability in different types of service. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse prescribing is becoming increasingly common in mental health services, changing roles for nurses and the experience of services for service users. However, there is great variation between organisations in this regard. Research is needed regarding the outcomes and any risks of independent nurse prescribing specifically in mental health compared to medical prescribing.

ABSTRACT

Introduction This paper reports the latest in a series of national surveys of nurse prescribing in mental health organizations in England. Aim To describe and understand changes and trends in the use of nurse prescribing nationally. Methods Postal survey to all 53 National Health Service Mental Health Trusts (publicly funded provider organizations); 75% responded (n = 40). Results Numbers of nurse prescribers (NPs) have grown significantly in the last 6 years, although remain a small percentage of the total Mental Health Nursing workforce. Most NPs are in community services, particularly community mental health teams and drug/alcohol services. Independent prescribing has now become the most common form of NP, replacing supplementary prescribing. Discussion Overall growth in numbers of NPs has continued, but remains marked by large variance in numbers between organizations. The study evidences that the particular form of nurse prescribing will influence its applicability in different clinical settings and that sustained increase over time in NP numbers is feasible at a national level, even with local variation in uptake. Implications for practice Nurse prescribing has become well embedded in many organizations although large-scale adoption may be hindered by the lack of a definitive evidence base as to outcomes compared with those from medical prescribing.

Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: An integrative review

BACKGROUND

Well validated clinical decision rules exist to facilitate the safe removal of collars in the alert, orientated, low risk adult trauma patient, however this practice is traditionally conducted by medical staff. The aim of this review is to synthesise current evidence to determine the efficacy of emergency nurses in safely and accurately removing cervical spine collars using cervical spine rules, in alert, orientated, low risk trauma adult patients.

METHODS

A multi-method search strategy was used to find primary research studies followed by a rigorous screening and quality appraisal process. Data from included articles were extracted, grouped and synthesised.

RESULTS

Nine quantitative research articles resulted in four key findings: the inter-rater reliability between nurses and doctors clearing the cervical spine was high (kappa range (0.61-0.80)); nurses can safely implement the cervical spine clinical decision rule; use of a cervical spine clinical decision rule decreases the time patients are immobilised and; nurses felt confident applying a cervical spine clinical decision rule.

CONCLUSION

Appropriately trained emergency nurses can safely apply cervical spine rules to alert, orientated, low risk adult trauma patients. Implementation of nurses clearing cervical spines should include training and ongoing monitoring.

Use and evaluation of a mentoring scheme to promote integration of non-medical prescribing in a clinical context

BACKGROUND

Growing numbers of non-medical health professionals are attaining prescribing rights through post-registration non-medical prescribing (NMP) courses in the UK. However, not all implement prescribing post-qualification. This study evaluated the uptake and perceived usefulness of a mentoring scheme for two cohorts of NMP students at the University of Nottingham. The scheme paired students with qualified mentors with whom they had an opportunity to discuss the integration of prescribing theory into practice.

METHODS

Mentors were allocated on days 2-5 of the course. Surveys were distributed to students who completed the NMP course [n = 63] and their mentors. Likert-scale and open-ended questions addressed: use, perceived usefulness, and positive and negative aspects of the mentoring scheme. Semi-structured interviews were conducted with both students (n = 6) and mentors (n = 3) to explore their experience of the mentoring scheme in more detail. Students were purposively selected for interview depending on their level of use of the mentoring system. Interviews were analysed using thematic analysis.

RESULTS

The response rates were 65.1% (n = 41) and 56.3% (n = 36) for students and mentors respectively. Just over half of students (57.1%) accessed their mentor. Having a sufficient support network was the key reason for not using the scheme. Students found mentors helpful for: moral support (68.2%); contextualising prescribing (71.4%); and helping them to think about implementing prescribing in practice (72.7%). Fewer mentors felt they helped in relation to contextualising (57.9%) or implementing prescribing (31.6%). Less than half the students and mentors surveyed agreed that they received/provided assistance related to the integration of prescribing theory into practice (38.1% and 42.2% respectively) and assistance with assignments (36.3% and 45.5% respectively).Interviews suggested that students found it difficult to focus on implementing prescribing because of the academic demands of their course, which impacted on uptake and use of the mentoring scheme. Students emphasised the importance of being paired with a prescriber who was successfully prescribing. Mentors benefited from sharing and refreshing their academic knowledge.

CONCLUSIONS

Students and mentors derived benefits from participation in this scheme. This intervention may be better as a post-qualification support resource when students are ready to consider their future prescribing practice.

Realizing nursing: a multimodal biopsychopharmacosocial approach to psychiatric nursing

The biological and psychosocial components of health, illness and treatment are well recognized. In addition, pharmacological interventions interact with both these components regarding health and illness; all components are potentially modifiable. A better understanding of these interactions on the course of illness, especially at the interface between illness and treatment, is needed to guide effective clinical and psychiatric nursing interventions. To this end, a multimodal biopsychopharmacosocial approach to assessment, formulation, care planning and implementation by psychiatric nurses is proposed. It is argued that a biopsychopharmacosocial approach, including a multimodal functional element, provides a person-centred, responsive and responsible basis for a comprehensive approach to practice. The use of this approach will improve intervention outcomes and contribute to the ongoing development of psychiatric nursing practice. It is suggested that, in part, this will be achieved through innovative teaching methods delivered by 'expert nurses' and clinical academics.

Experiences of nurses as postgraduate students of pharmacology and therapeutics: a multiple case narrative study

BACKGROUND

Pharmacology and therapeutics are essential components of educational programmes in prescribing, yet little is known about students' experiences in studying these subjects for a prescribing role.

OBJECTIVE

To investigate the views and experiences of nurses as postgraduate students who were studying pharmacology and therapeutics in preparation for a prescribing role.

DESIGN

Qualitative study using a multiple case narrative approach.

SETTINGS

The participants were undertaking or had recently completed a Master's degree programme; they worked in a range of clinical areas and services in the Auckland region.

PARTICIPANTS

Twenty nurses, with advanced clinical backgrounds and experience engaged in postgraduate studies in pharmacology and therapeutics.

METHODS

A semi-structured interview of approximately 1h was undertaken with each participant. Transcripts were analysed within and across cases using Narralizer software to support thematic analysis.

RESULTS

There were four broad thematic areas. In the first, 'prescribing in the context of advanced nursing practice', participants reflected on why prescribing authority was important to them. In the second theme, 'adequacy of prior pharmacology knowledge' they discussed the relative lack of pharmacology in their undergraduate programmes and in nursing practice. In the third, 'drawing on clinical experience in acquiring pharmacology knowledge', participants discussed how, as they grappled with new pharmacological science, they drew on clinical experience which facilitated their learning. In the fourth theme, 'benefits of increased pharmacology knowledge' they discussed how their studies improved their interactions with patients, medical colleagues and as members of multi-disciplinary teams.

CONCLUSIONS

All nurses viewed their studies in pharmacology as fundamental to their roles as prescribers, through knowledge development and an increase in confidence. Although pharmacology theory was new to many participants, their learning was facilitated because they were able to reflect on previous clinical experience and apply this to theory.

An evaluation of team and individual formularies to support independent prescribing in mental health care

Mental health nurses have been entitled to train to become independent prescribers since May 2006; although the number of trained nurse prescribers seems to have increased steadily, a significant number of them have not actually undertaken prescribing roles on completion of their training or have limited their practice to supplementary prescribing. In order to support existing independent prescribers and to assist those nurses who have trained but are yet to prescribe independently, a mental health trust has piloted the use of individual and team formularies. An evaluation of this project indicated that formularies were well received by existing independent prescribers and were seen as a helpful instrument to support newly qualified and supplementary prescribers in their bid to become independent. Formularies can clarify and formalize each prescriber's area of competence, thus setting clear boundaries, reducing uncertainty and enhancing prescribers' confidence and willingness to take on this new role. Formularies may also be used to enhance communication with service users and further develop shared decision making. Effective procedures need to be in place to ensure formularies are up to date and reflect local practice.

Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a systematic review of the literature

Background

A growing number of countries are introducing some form of nurse prescribing. However, international reviews concerning nurse prescribing are scarce and lack a systematic and theoretical approach. The aim of this review was twofold: firstly, to gain insight into the scientific and professional literature describing the extent to and the ways in which nurse prescribing has been realised or is being introduced in Western European and Anglo-Saxon countries; secondly, to identify possible mechanisms underlying the introduction and organisation of nurse prescribing on the basis of Abbott's theory on the division of professional labor.

Methods

A comprehensive search of six literature databases and seven websites was performed without any limitation as to date of publication, language or country. Additionally, experts in the field of nurse prescribing were consulted. A three stage inclusion process, consisting of initial sifting, more detailed selection and checking full-text publications, was performed independently by pairs of reviewers. Data were synthesized using narrative and tabular methods.

Results

One hundred and twenty-four publications met the inclusion criteria. So far, seven Western European and Anglo-Saxon countries have implemented nurse prescribing of medicines, viz., Australia, Canada, Ireland, New Zealand, Sweden, the UK and the USA. The Netherlands and Spain are in the process of introducing nurse prescribing. A diversity of external and internal forces has led to the introduction of nurse prescribing internationally. The legal, educational and organizational conditions under which nurses prescribe medicines vary considerably between countries; from situations where nurses prescribe independently to situations in which prescribing by nurses is only allowed under strict conditions and supervision of physicians.

Conclusions

Differences between countries are reflected in the jurisdictional settlements between the nursing and medical professions concerning prescribing. In some countries, nurses share (full) jurisdiction with the medical profession, whereas in other countries nurses prescribe in a subordinate position. In most countries the jurisdiction over prescribing remains predominantly with the medical profession. There seems to be a mechanism linking the jurisdictional settlements between professions with the forces that led to the introduction of nurse prescribing. Forces focussing on efficiency appear to lead to more extensive prescribing rights.

Make a CHANGE: optimising communication and pain management decisions

The major objectives of the CHANGE PAIN International Advisory Board are to enhance understanding of chronic pain and to develop strategies for improving pain management. At its second meeting, in November 2009, evidence was presented that around one person in five in Europe and the USA experiences chronic pain, and the delay before referral to a pain specialist is often several years. Moreover, physicians' pharmacological approach to chronic pain is inconsistent, as evidenced by the huge variation in treatment between different European countries. It was agreed that efficient communication between physician and patient is essential for effective pain management, and that efficacy/side-effect balance is a key factor in choosing an analgesic agent. The multifactorial nature of chronic pain produces various physical and psychological symptoms, so the management of chronic pain should be tailored to the individual. Pharmacological therapy must be matched to the causative mechanisms responsible, or it is likely to prove ineffective and risk the development of a 'vicious circle'; doses are increased because of inadequate pain relief, but this increases side-effects so doses are reduced, pain relief is then inadequate, so doses are increased, and so on. Pain management decisions should not therefore be based solely on the severity of pain. Based on the concept of individual treatment targets (ITT), the CHANGE PAIN Scale was adopted - a simple, user-friendly assessment tool to improve communication between physician and patient. The 11-point NRS enables the patient to rate the current pain intensity and to set a realistic individual target level. On the reverse are six key parameters affecting the patient's quality of life; clinicians simply need to agree with patients whether improvement is needed in each one. Regular use can establish the efficacy and tolerability of pain management, and the rate of progress towards individual treatment targets.

Further challenges to medical dominance? The case of nurse and pharmacist supplementary prescribing

Doctors have traditionally been viewed as the dominant healthcare profession, with the authority to prescribe medicines, but recent non-medical prescribing initiatives have been viewed as possible challenges to such dominance. Using the example of the introduction of supplementary prescribing in the UK, this study sought to explore whether such initiatives represent a challenge to medical authority. Ten case study sites in England involving primary and secondary care and a range of clinical areas were used to undertake a total of 77 observations of supplementary prescribing consultations and interviews with 28 patients, 11 doctors and nurse and pharmacist prescribers at each site. Supplementary prescribing was viewed positively by all participants but several doctors and patients appeared to lack awareness and understanding of supplementary prescribing. Continued medical authority was supported empirically in five areas: patients' and supplementary prescribers' perception of doctors as being hierarchically superior; doctors legitimation of nurses' and pharmacists' prescribing initially; doctors' belief that they could control (particularly nurses') access to prescribing training; supplementary prescribers' frequent recourse to use doctors' advice, coupled with doctors' encouragement of such 'knock on door' prescribing advice policies; doctors' denigration of most routine prescribing but claims that diagnosis was more skilled and key to medicine. Supplementary prescribing appeared to be successfully accomplished in practice in a range of clinical settings and was acceptable to all involved but did not ultimately challenge medical dominance. However, more recent nurse and pharmacist independent prescribing (involving diagnosis) may represent a more significant threat.

Pharmacology podcasts: a qualitative study of non-medical prescribing students' use, perceptions and impact on learning

BACKGROUND

There is growing research on student use of podcasts in academic settings. However, there is little in-depth research focusing on student experience of podcasts, in particular in terms of barriers to, and facilitators of, podcast use and students' perceptions of the usefulness of podcasts as learning tools. This study aimed to explore the experiences of non-medical prescribing students who had access to podcasts of key pharmacology lectures as supplementary learning tools to their existing course materials.

METHODS

Semi-structured interviews were carried out with seven non-medical prescribing students (average age = 43 years), all of whom were nurses, who had access to seven podcasts of key pharmacology lectures. These podcasts took the form of downloadable audio lecture recordings available through the virtual learning environment WebCT. Low, medium and high users of the podcasts took part in the interviews in order to access a variety of student experiences. Interview data was analysed using thematic template analysis to identify key themes surrounding student experience of podcast availability, particularly in relation to barriers to and facilitators of podcast use, and students' experiences of podcasts as a learning tool.

RESULTS

Students used podcasts for a variety of reasons such as revisiting lectures, preparing for exams, to clarify or revise specific topics and, to a lesser extent, to catch up on a missed lecture. Barriers to podcast use centred mainly around technological issues. Lack of experience of the technology required to access podcasts proved a barrier for some students. A lack of access to suitable technology was also a reported barrier. Family assistance and I.T. assistance from the university helped facilitate students' use of the podcasts. Students found that using podcasts allowed them to have greater control over their learning and to gauge their learning needs, as well as helping them build their understanding of a complex topic.

CONCLUSIONS

Students used podcasts for a variety of reasons. Barriers to podcasts use were generally related to technological issues. Students often found that once assistance had been gained regarding these technological issues, they accessed the podcasts more easily. Students felt that access to podcasts added value to their learning materials by allowing them to better manage their learning and build their understanding. Podcasts represent a valuable additional learning tool for this specific group of older students.

Two hundred days of nurse practitioner prescribing and role development: a case study report from a hospital-based acute pain management team

Purpose. This report evaluates a beginning Nurse Practitioner (NP) role in Acute Pain Management. Healthcare setting. The role was implemented within an anaesthesiology-based pain service. The NP author developed this pain service in 2002 and was endorsed as an NP 6 years later. The NP reviews all clients undergoing major surgery or trauma and provides pain management to women for caesarean section. Prior to this role, there were significant delays for some patients requiring prompt analgesia. This was because of the decreased availability of anaesthetists to fully participate in the pain service due to the demand for complex anaesthesiology practice. Method of data collection. Data were conveniently collected by the NP on prescription and service provision over 200 working days. Main findings. Therapeutic activity reflected contemporary pain management practice and espouse the NP as a safe and effective clinician. The role has improved patient access to pain management through the prompt use of non-pharmacological interventions, drugs used to treat analgesic side effects, opioids and non-opioid analgesics. Principal conclusions. These initial positive outcomes are consistent with NP role development described elsewhere in Australia and overseas across a variety of healthcare settings. To sustain this role, robust continuing education and clinical support is required. What is known about the topic? There is little published information on the development of the Nurse Practitioner (NP) role in acute pain services in Australia or overseas. The acute pain role is a new development in Australia and so previous descriptions of NP practice have focussed on other specialty areas such as Emergency or Mental Health. What does this paper add? This report demonstrates positive and safe client outcomes as a result of a NP role in acute pain management. More importantly, it may contribute to accumulating evidence that NPs are safe prescribers of opioids and other analgesics in acute settings. What are the implications for practitioners? Novice NPs and Candidates practising in this specialty need to use this information as support for their own role development and implementation in other acute pain services in Australia.

Administrative claims data analysis of nurse practitioner prescribing for older adults

AIM

This paper is a report of a study to identify the patterns of prescribing by primary health care nurse practitioners for a cohort of older adults.

BACKGROUND

The older adult population is known to receive complex pharmacotherapy. Monitoring prescribing to older adults can inform quality improvement initiatives. In comparison to other countries, research examining nurse practitioner prescribing in Canada is limited. Nurse practitioner prescribing for older adults is relatively unexplored in the international literature. Although commonly used to study physician prescribing, few studies have used claims data from drug insurance programmes to investigate nurse practitioner prescribing.

METHOD

Drug claims for prescriptions written by nurse practitioners from fiscal years 2004/05 to 2006/07 for beneficiaries of the Nova Scotia Seniors' Pharmacare programme were analysed. Data were retrieved and analysed in May 2008. Prescribing was described for each drug using the World Health Organization Anatomical Therapeutic Chemical code classification system by usage and costs for each fiscal year.

RESULTS

Antimicrobials and non-steroidal anti-inflammatory drugs consistently represented the top ranked groups for prescription volume and cost. Over the three fiscal years, antimicrobial prescription rates declined relative to rates of other groups of medications. Prescription volume per nurse doubled and cost per prescription increased by approximately 20%.

CONCLUSION

Prescription claims data can be used to characterize the prescribing trends of nurse practitioners. Research linking patient characteristics, including diagnoses, to prescriptions is needed to assess prescribing quality. Some potential areas of improvement were identified with antimicrobial and non-steroidal antiinflammatory selection.

Does psychopharmacology training enhance the knowledge of mental health nurses who prescribe?

The implementation of Mental Health Nurse (MHN) prescribing in the UK remains disappointing. A much cited critique of MHNs prescribing is that it would be unsafe, as MHN would not have the appropriate knowledge of pharmacology to practise mental health prescribing. The knowledge of pharmacology of MHNs with the prescribing qualification has not been assessed in the UK. In addition, the views of MHNs with the prescribing qualification who have undertaken a psychopharmacology course have not been explored. The aims of this study are to measure the efficacy of a 10-day advanced training programme on psychopharmacology on the knowledge levels of MHNs with the prescribing qualification; and to explore the positive and negative experiences of individual participants of the training in psychopharmacology and how it supported their prescribing practice. A repeated measures design was used in which participants acted as their own controls. Participants were assessed 10 weeks before the training programme and again on day one of the training programme using a Multiple Choice Questionnaire. In addition, a series of focus groups were conducted to explore the helpful and unhelpful aspects of the course in sustaining the MHNs' prescribing practice. Following the training period there were significant increases in the MHNs' knowledge of psychopharmacology in comparison with the two base line means. Participants when interviewed 18 months after completing the training described the training as a helpful though they described it had not resulted in large increases in prescribing practice, citing systemic barriers to its implementation. Short and focussed training for MHNs who prescribe may increase their knowledge of psychopharmacology. The development of such programmes may well be part of the solution to support MHNs with the prescribing qualification to prescribe, supported by the views of the MHNs who participated in the focus groups. However, further work is required to remove organizational barriers. The data raise questions both about the current suitability of nurse prescribing preparation programmes in the UK and the suitability of NHS settings to support MHN to prescribe.

Nurse prescribing in mental health: national survey

Mental health nurses can now train to become independent prescribers as well as supplementary prescribers. Independent nurse prescribing can potentially help to reorganize mental health services, increase access to medicines and improve service user information, satisfaction and concordance. However, mental health nursing has been slow to undertake prescribing roles, and there has been little work conducted to look at where nurse prescribing is proving successful, and those areas where it is less so. This survey was designed to collect information from directors of nursing in mental health trusts about the numbers of mental health prescribers in England, gather views about prescribing in practice, and elicit intentions with regards to the development of nurse prescribing. In some Trusts, the number of mental health nurse prescribers has increased to the point where wider impacts on workforce, the configuration of teams and services are inevitable. Currently, the way that prescribing is used within different organizations, services and teams varies and it is unclear which setting is most appropriate for the different modes of prescribing. Future work should focus on the impact of mental health nurse prescribing on service delivery, as well as on service users, colleagues and nurses themselves.

Causes and management of nursing practice errors: a questionnaire survey of hospital nurses in Iran

BACKGROUND

Some human error in health care is inevitable. Research into the predisposing factors for these errors is an important step in their management.

AIM

To survey nurse perceptions of the contributing factors to nursing practice errors.

METHODS

A descriptive survey was carried out in three selected educational hospitals in Tehran city. Data were collected by questionnaire and analysed using descriptive statistics. The study sample consisted of 96 nurses and nursing managers. A multistage sampling strategy was used.

RESULTS

Results showed that from nurses' and nursing managers' perspectives, various factors could contribute to the occurrence of nursing errors in the 'management', 'environment' and 'nursing care' sections. In addition, there were differences between nurses working on various wards about the causes of nursing errors in each section.

CONCLUSION

A culture of safety recognizes that safety is 'no accident'. Rather, it requires a change in management practices, providing a suitable environment with the requisite supply of resources and infrastructure, and increasing nurses' knowledge. Outcomes that are identified from the process of practice error management should promote interventions designed to prevent future practice errors based on the above contributing factors.

LIMITATIONS

The study relied on self-report by a sample of nurses. These responses should now be tested by empirical research into actual nursing practice errors in order to test whether the nurses' perceived ideas of causation are substantiated.

Mental health nurse prescribing in New Zealand and the United kingdom: comparing the pathways

PURPOSE

Prescriptive authority in the area of mental health care is significantly different between New Zealand and the United Kingdom. Exploring the educational preparation and context differences aids understanding of the present dearth of mental health nurse prescribers in New Zealand.

CONCLUSIONS

The barriers experienced in implementation and extension of prescribing rights have been similar in both countries.

PRACTICE IMPLICATIONS

Until roles change, registered nurses in New Zealand may be reluctant to undertake the challenging and demanding step to gain prescribing rights. The potential for nurses to make a difference in the lives of people with mental illness in New Zealand is therefore constrained.

Pharmacology education for nurse prescribing students - a lesson in reusable learning objects

Background

The shift away from a biological science to a social science model of nursing care has resulted in a reduction in pharmacology knowledge and understanding in pre-registration nursing students. This has a significant impact on nurse prescribing training where pharmacology is a critical component of the course from a patient safety perspective.

Methods

Reusable learning objects (RLOs) are electronic resources based on a single learning objective which use high quality graphics and audio to help engagement with the material and to facilitate learning. This study used questionnaire data from three successive cohorts of nurse prescribing students (n = 84) to evaluate the use of RLOs focussed around pharmacology concepts to promote the understanding of these concepts in students. A small number of students (n = 10) were followed up by telephone interview one year after qualification to gain further insight into students' perceptions of the value of RLOs as an educational tool.

Results

Students' perceptions of their own understanding of pharmacology concepts increased substantially following the introduction of RLOs to supplement the pharmacology component of the course. Student evaluation of the RLOs themselves was extremely positive with a number of students continuing to access these tools post-qualification.

Conclusion

The use of RLOs to support the pharmacology component of nurse prescribing courses successfully resulted in a perceived increase in pharmacology understanding, with some students directly implicating these educational tools in developing confidence in their own prescribing abilities.