How do nurse prescribers integrate prescribing in practice: case studies in primary and secondary care

Nurses' readiness to prescribe under supervision in Saudi Arabia: A cross-sectional study

Aim

To explore nurses' readiness to prescribe medications under supervision and identify associations between prescribing practices under supervision and demographic characteristics in Saudi Arabia.

Design

A cross-sectional study.

Methods

Using convenience sampling, this study used a 32-item survey to collect data on nurses prescribing medications under supervision between December 2022 and March 2023.

Results

A total of 379 nurses were recruited from different regions in Saudi Arabia. Approximately 7% (n = 30) of the participants were prescribing medications independently, and 70% (n = 267) expressed their likelihood of becoming prescribers. The highest motivating factors to become prescribers were improvement of patient care (52.2%) and contribution to the multidisciplinary team (52.0%). Most participants (60%-81%) agreed that prescribing medications under supervision would improve potential outcomes at the system, nurse, and patient levels. Availability of appropriate mentors or supervisors (72.9%) was the highest rated facilitating factor, followed by support of nursing colleagues (72%). Based on demographic characteristics, findings revealed significant differences in the: a) likelihood and motivators of becoming prescribers; b) required minimum qualification, years of experience, and continuing professional education hours to become prescribers; and c) type of organizations delivering educational programs for nurse prescribing.

Conclusion

Majority of nurses in Saudi Arabia favored becoming prescribers, and motivating factors were mostly relevant to optimizing patient care outcomes. Having the proper supervision was rated as the most facilitating factor for nurse prescribing. Nurses' views on potential outcomes, facilitating factors, and possible motivators varied based on nurses' demographical characteristics.

Implications for the professional and/or patient care

Nurses favored prescribing under supervision to improve patient care outcomes, which is an opportunity to expand the benefits of health services, including easy access to healthcare.

Impact

Results revealed that nurses support the implementation of prescribing practice under supervision. Thus, the findings may inform practice change in Saudi Arabia to allow prescribing under supervision, which was perceived to have a positive impact on patient care outcomes.

Reporting Method

This study adhered to STROBE guidelines.

Community Health Nurses' Perspective on the Introduced Rational Drug Use Policy in Primary Care Settings in Thailand: A Descriptive Qualitative Study

BACKGROUND

To address the problems related to drug resistance and medication safety, the rational drug use (RDU) policy has been implemented in Thailand since 2014. Theoretically, the policy was supposed to bring drastic changes to the way clinicians prescribe medications and its impacts on clinical practice, however, it has not yet been investigated. The study aimed to describe the experience of community health nurses with regard to the impact of RDU policy implementation on their practices.

METHODS

Focus group interviews and in-depth interviews with community nurses were conducted. Thematic analysis was performed.

RESULTS

Five themes emerged from the analysis, namely, (1) a welcome opportunity, (2) RDU as the quality of healthcare, (3) multidisciplinary collaboration, (4) reinventing productive interactions between nurses and patients, and (5) challenges over control of medications prescribed or purchased elsewhere.

CONCLUSIONS

Implementing RDU in primary care provides opportunities for protecting individual patients and public health as well as safeguarding against professional prescription error. This can be made possible by adopting a systemic approach to changes. Additional educational and organizational support will optimize health professionals' contribution to the implementation and hence optimal outcomes of this important policy.

Barriers and facilitators to implementation of non-medical independent prescribing in primary care in the UK: a qualitative systematic review

OBJECTIVES

To support workforce deficits and rising demand for medicines, independent prescribing (IP) by nurses, pharmacists and allied health professionals is a key component of workforce transformation in UK healthcare. This systematic review of qualitative research studies used a thematic synthesis approach to explore stakeholders' views on IP in primary care and identify barriers and facilitators influencing implementation.

SETTING

UK primary/community care.

PARTICIPANTS

Inclusion criteria were UK qualitative studies of any design, published in the English language. Six electronic databases were searched between January 2010 and September 2021, supplemented by reference list searching. Papers were screened, selected and quality-appraised using the Quality Assessment Tool for Studies with Diverse Designs. Study data were extracted to a bespoke table and two reviewers used NVivo software to code study findings. An inductive thematic synthesis was undertaken to identify descriptive themes and interpret these into higher order analytical themes. The Diffusion of Innovations and Consolidated Framework for Implementation Research were guiding theoretical anchors.

PRIMARY AND SECONDARY OUTCOME MEASURES

N/A.

RESULTS

Twenty-three articles addressing nurse, pharmacist and physiotherapist IP were included. Synthesis identified barriers and facilitators in four key stages of implementation: (1) 'Preparation', (2) 'Training', (3) 'Transition' and 4) 'Sustainment'. Enhancement, substitution and role-specific implementation models reflected three main ways that the IP role was used in primary care.

CONCLUSIONS

In order to address global deficits, there is increasing need to optimise use of IP capability. Although the number of independent prescribers continues to grow, numerous barriers to implementation persist. A more coordinated and targeted approach is key to overcoming barriers identified in the four stages of implementation and would help ensure that IP is recognised as an effective approach to help alleviate workforce shortfalls in the UK, and around the world.

PROSPERO REGISTRATION NUMBER

CRD42019124400.

A survey of nurses prescribing in diabetes care: Practices, barriers and facilitators in New Zealand and the United Kingdom

AIMS AND OBJECTIVES

To compare diabetes-related prescribing practices, barriers and facilitators amongst nurse prescribers in New Zealand and the United Kingdom.

BACKGROUND

Nurses have been prescribing in the United Kingdom for many years but nurse prescribing in New Zealand is relatively recent. It is unknown whether similar system factors act to facilitate or limit prescribing.

DESIGN

A survey of 250 nurses prescribing in diabetes care in New Zealand (n = 111) and the United Kingdom (n = 139).

METHODS

A SurveyMonkey questionnaire was used to survey nurses about the extent of their prescribing practices, and barriers and facilitators experienced. Quantitative data were explored descriptively, and qualitative responses were grouped according to content, with quotes provided to exemplify thematic content. This study is reported following STROBE guidelines.

RESULTS

Insulin, metformin and sulphonylureas are the drugs most frequently prescribed in both countries. Considerably more New Zealand than United Kingdom nurses reported prescribing for cardiovascular and renal disease. In both countries, direct prescribing to the patient was most common, followed by remote prescribing in New Zealand and via recommendation to other prescribers in the United Kingdom. Most common barriers were lack of time and inadequate mentoring. Most common facilitators were as follows: good supervision; collegial relationships with specialists, pharmacists and peers; and ongoing education.

CONCLUSIONS

These New Zealand and United Kingdom nurses are prescribing a broad range of diabetes-related medications. Similar barriers and facilitators were identified in both countries. Adequate supervision, support from multidisciplinary team colleagues and prescribing education and guidelines are paramount.

RELEVANCE TO CLINICAL PRACTICE

Important insights on barriers and facilitators to implementation of nurse prescribing in two countries are highlighted and, despite a considerable difference in the longevity of prescribing practice, similar issues were identified.

Evidence-informed implementation of nurse prescribing under supervision: An integrative review

AIM

To explore evidence reporting facilitators and barriers to implementation of nurse prescribing and provide practical recommendations for evidence-informed implementation and adoption of nurse prescribing under a supervision model.

BACKGROUND

As demand for access to quality health care services increases, health professional roles are expanding to meet population needs. Nurse prescribing has been effective in some countries and is being considered globally to address growing health care demand. Successful implementation of health service models requires careful planning and consideration. No existing reviews have examined implementation factors in the literature.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, MEDLINE, PubMed and EMBASE databases were searched from inception to 15 April 2020.

REVIEW METHODS

This integrative review is guided by Whittemore and Knafl and adheres to PRISMA reporting guidelines. The sustainability of innovation framework was used to synthesize data concerning implementation and sustainability factors (i.e. innovation, organizational, political, workforce and financial) for nurse prescribing.

RESULTS

A total of 39 articles were reviewed with literature predominantly reporting findings related to non-medical and nurse prescribing under various models. Variable evidence was found to inform nurse prescribing across five implementation and sustainability factors identifying several areas that require in-depth consideration. Very little evidence is available on nurse prescribing under supervision.

CONCLUSION

Introduction of service reform is often costly. This review highlights gaps in the literature and raises areas for consideration prior to implementation of this new service delivery model. The introduction of nurse prescribing must be planned and informed by available evidence to support effective adoption, practice and patient outcomes.

IMPACT

There are significant gaps in evidence related to nurse prescribing under a supervision model. Based on the evidence synthesized in this review, this paper provides practical recommendations for health service providers, managers, clinicians, educators and researchers to support implementation and adoption of nurse prescribing.

Factors influencing the prescribing behaviour of independent prescriber optometrists: a qualitative study using the Theoretical Domains Framework

PURPOSE

Whilst the number of independent prescriber (IP) optometrists in the United Kingdom is increasing, there is limited evidence describing the experiences of these individuals. The Theoretical Domains Framework (TDF) provides an evidence-based approach to understand determinants of behaviour. This conceptual framework can enable mapping to the COM-B behaviour change model and the wider Behaviour Change Wheel to develop interventions to optimise behaviour-change and healthcare processes more systematically. The study aimed to use the TDF to identify the factors that influence independent prescribing behaviour, and to map these findings to the COM-B system to elucidate the relevant intervention functions, in order to identify the support required by optometrist prescribers.

METHODS

Using a qualitative design, semi-structured interviews based on the TDF were undertaken with independent prescriber optometrists. Thematic analysis was used to identify themes inductively, which were then deductively mapped to the TDF and linked to the COM-B.

RESULTS

Sixteen participants (9 male, 7 female; median age 45 years, range 28-65 years), based in community (n = 10) and hospital (n = 6) settings, were interviewed. Eleven of the TDF domains were found to influence prescribing behaviour. Findings highlighted the need for good communication with patients (TDF domain: Skills, COM-B: Capability); confidence (TDF domain: Beliefs about capabilities, COM-B: Motivation); good networks and relationships with other healthcare professionals, e.g., general practitioners (TDF domain: Social influences, COM-B: Opportunity; TDF domain: Social/professional role and identity, COM-B: Motivation); the need for appropriate structure for remuneration (TDF domain: Reinforcement, COM-B: Motivation; TDF domain: Social/professional role and identity, COM-B: Motivation) and the provision of professional guidelines (TDF domain: Knowledge, COM-B: Capability; TDF domain: Environmental context and resources, COM-B Opportunity).

CONCLUSIONS

Having identified theory-derived influencers on prescribing decisions by optometrists, the findings can be used to develop a structured intervention, such as a support package to help optimise prescribing by optometrists, with the ultimate goal of eye care quality improvement.

Experiences of registered nurse prescribers; a qualitative study

Aims: This study aimed to investigate the experiences of registered prescribers and their perceptions of the enablers and barriers to registered prescribing and the value of this fledgling role. Background: The role of prescribing has been extended to registered nurses in New Zealand. By adding the designated prescribing role to a nurse's role, their scope of practice expands and nurses are able to provide patients with holistic care while achieving greater independence and role satisfaction. Yet new nurse prescribers can experience anxiety and fear when confronted with the reality of the responsibility of prescribing. Methods: Sixteen semi-structured interviews were conducted with registered nurse prescribers across New Zealand. Data were analysed using a general inductive approach and thematic analysis utilised to identify themes and sub-themes. Results: Sixteen registered nurse prescribers participated in the study. Three main themes emerged with sub-themes: ability to expand practice, improving access to care, and importance of working in a collaborative team. Participants explained how they enjoyed the challenge and responsibility of the new prescribing role yet were frustrated with the realities of the restrictions of what they could actually prescribe and in some cases lack of role recognition. Registered nurse prescribing also improved access to care as nurses felt they provided more comprehensive care, resulting in reduced wait times, better continuity of care and a reduction in patient costs. The participants highlighted the importance of working in a collaborative team and believed their ability to prescribe maximised clinician time, however cautioned the need for on-going clinical mentorship and a prepared and supportive work environment. Conclusions: The addition of registered nurse prescribing provides a number of advantages to individual nurses in terms of career development and job satisfaction, and to patients and the health care system. The benefits to health care consumers and the health care system align directly to health care priorities of improving equity and access to care. Impact statement: Registered nurse prescribers perceive a number of advantages to the addition of prescribing to their own practice and benefits to patients and the health care system by enabling more accessible and cost-effective care.

Clinical nurse specialist prescribing in a cancer centre supportive and palliative care team

OBJECTIVE

To provide insight into the prescribing practices of three independent nurse prescribers (INPs)/clinical nurse specialists (CNSs) working in a supportive and palliative care team (SPCT) in a district general hospital and a specialist tertiary cancer centre in the UK.

METHODS

A prospective review of all consultations and the prescribing activity arising from the consultations (and reasons for non-prescribing following a consultation) of 3 INPs/CNSs between 1 August 2018 and 31 October 2018.

RESULTS

Four hundred ninety-three consultations were undertaken on 186 individual patients. Two hundred forty-seven consultations representing 50% resulted in changes to a prescription, and 123 of those consultations representing 50% of prescriptions written resulted in the prescribing of an opioid for moderate-to-severe pain.

CONCLUSIONS

This service evaluation demonstrates the potential for INPs in SPCTs to provide comprehensive symptom control while enabling CNSs to practice with a greater degree of autonomy leading to enhanced job satisfaction. On the basis of our experience, we would encourage all palliative care CNSs to undergo training to become INPs (if available).

The role of nurse prescribers in memory services and their continuing professional development: A review of the literature

BACKGROUND

Nurse prescribers (NPs) in memory services have a potentially important role in alleviating the burden of dementia on health care, but they require continuing professional development (CPD) specific to their scope of practice.

AIMS

To inform development of CPD workshops for mental health NPs working in memory services, a review of the literature was undertaken regarding role and CPD issues of this professional group.

DESIGN AND METHODS

Healthcare databases were searched using defined search terms alongside lateral searches. Study characteristics were extracted systematically, with results grouped thematically in the style of a narrative review. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, adapted for current methods (see Supporting Information File S1).

RESULTS AND DISCUSSION

Nine articles specifically addressing nurse prescribing in memory services were found. Studies from broader areas were drawn upon. Considerable variation was found for how the role of memory service NPs might be defined, due in part to variation in characteristics of memory services. NPs, other clinical staff and patients have provided positive feedback to the introduction of the role in memory services and elsewhere. However, concerns around prescribing cautiousness of NPs were apparent. Little clinical or economic outcome data were found to compare opinions and experiences to, with none for NPs in memory services. Literature addressing CPD issues for NPs in memory services was nonexistent. Studies from surrounding areas suggest a problem with availability of CPD opportunities for nurse prescribers.

CONCLUSION

This review highlights the paucity of literature for this area of inquiry, particularly for clinical, economic and other patient outcome data.

RELEVANCE TO CLINICAL PRACTICE

Variation in the little existing evidence suggests development of CPD opportunities should spend time understanding issues at the local level. The gap in the literature in this area may impact policy decisions in the UK and elsewhere.

Classic e-Delphi survey to provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services in Wales

OBJECTIVE

To provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services.

DESIGN

Classic e-Delphi survey.

SETTING

National study in Wales.

PARTICIPANTS

Pharmacists, nurses and allied health professionals with the independent/supplementary prescribing qualification.

RESULTS

A total of 55 non-medical prescribers agreed to become members of the expert panel of whom 42 (76%) completed the round 1 questionnaire, 40/42 (95%) completed round 2 and 34/40 (85%) responded to round 3. Twenty-one statements were developed, and consensus was achieved on nine factors representing those necessary for the successful implementation of non-medical prescribing and five representing actions required for its continued development. Strategic fit between non-medical prescribing and existing service provision, organisation preparedness, visible benefits, good managerial and team support, and a clear differentiation of roles were each important influences.

CONCLUSION

Given the high degree of consensus, this list of factors and actions should provide guidance to managers and commissioners of services wishing to initiate or extend non-medical prescribing. This information should be considered internationally by other countries outside of the UK wishing to implement prescribing by non-medical healthcare professionals.

Facilitators and barriers to non-medical prescribing - A systematic review and thematic synthesis

Introduction

Non-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom.

Methods

The systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786).

Results

Of 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals’, ‘area of competence’, ‘impact on time’ and ‘service’. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances.

Discussion

Addressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists.

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.

[Nurse prescribing rights, the UK experience]

The United Kingdom has gradually introduced nurse prescribing. This authorisation is granted upon completion of a theoretical and practical training course. This evolution has been deemed to have had a positive impact twenty years after its implementation.

[Nurse prescribing, what is the international situation?]

Authorising nurses to prescribe is identified as a winning strategy for a growing number of healthcare systems looking to put in place an organisation better suited to the challenges facing them. However, it is necessary to establish the conditions necessary for its implementation, notably in terms of the acquisition and updating of skills as well as the preparation of the clinical environments in which to implement this change.

Developing the DESCARTE Model: The Design of Case Study Research in Health Care

Case study is a long-established research tradition which predates the recent surge in mixed-methods research. Although a myriad of nuanced definitions of case study exist, seminal case study authors agree that the use of multiple data sources typify this research approach. The expansive case study literature demonstrates a lack of clarity and guidance in designing and reporting this approach to research. Informed by two reviews of the current health care literature, we posit that methodological description in case studies principally focuses on description of case study typology, which impedes the construction of methodologically clear and rigorous case studies. We draw from the case study and mixed-methods literature to develop the DESCARTE model as an innovative approach to the design, conduct, and reporting of case studies in health care. We examine how case study fits within the overall enterprise of qualitatively driven mixed-methods research, and the potential strengths of the model are considered.

Factors influencing nurse and pharmacist willingness to take or not take responsibility for non-medical prescribing

BACKGROUND

In the UK, the majority of non-medical prescribers (NMPs) are nurses or pharmacists working in community or primary care. However, little is known about what influences their decisions to prescribe, unlike with medical prescribing. It is also unclear whether the medical findings can be extrapolated, given their very different prescribing training.

OBJECTIVES

To explore the factors influencing whether nurse and pharmacist NMPs in community and primary care settings take responsibility for prescribing.

METHODS

Initially, 20 NMPs (15 nurses and 5 pharmacists) were purposively selected and interviewed using the critical incident technique about situations where they felt it was inappropriate for them to take responsibility for prescribing or where they were uneasy about doing so. In addition, more general factors influencing their decision to take or not take prescribing responsibility were discussed. Subsequently, the themes from the interview analysis were validated in three focus groups with a total of 10 nurse NMPs. All data were analyzed using a constant comparison approach.

RESULTS

Fifty-two critical incidents were recorded--12 from pharmacist NMPs and 40 from nurse NMPs. Participants experienced situations where they were reluctant to accept responsibility for prescribing. Perceptions of competency, role and risk influenced their decision to prescribe. Workarounds such as delaying the prescribing decision or refer the patient to a doctor were used.

CONCLUSIONS

For NMPs to feel more confident about taking responsibility for prescribing, these issues of competency, role and perceived risk need to be addressed. Roles of NMPs must be clear to colleagues, doctors and patients. Training and support must be provided to enable professional development and increasing competence of NMPs.

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.