Advanced practice nurses' experiences and well-being: Baseline demographics from a cohort study

AIMS

To create a cohort of advanced practice nurses from across the UK and to report the initial questionnaire including demographics, work experiences and well-being.

BACKGROUND

In the UK, advanced nursing practice is not regulated. This has led to the concern that advanced nurses are working in very different ways with different levels of autonomy and support.

METHODS

Participants were recruited via university and Royal College of Nursing mailing lists, and social media adverts. They completed the initial questionnaire about their background and workplace, work experiences, credentialing and well-being.

RESULTS

A total of 143 nurses were recruited to the cohort and 86 completed the survey. Over 40 job titles were reported, across five pay bands. Job title was not correlated with pay band (p = .988). Participant well-being was not significantly different from the UK general population, but they reported high rates of work-related stress (44.2%) compared with the National Health Service national average (37.9%).

CONCLUSION

There is a wide disparity in pay, which is not reflected in title or setting. The high levels of work-related stress require further exploration.

IMPLICATIONS FOR NURSING MANAGEMENT

The range of experiences reported here should encourage managers to evaluate whether title, pay and support mechanisms for Advanced Practice Nurses in their organisations align with suggested national standards set by Royal Colleges and government departments.

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.

The Implementation Process of Nurse Prescribing in Poland-A Descriptive Study

The study aimed to investigate the situation of nurse prescribing, introduced in Poland in 2016, by analyzing the opinions of nurses, expected to be influential on nurses' actual practices, in response to legislative change to enable nurses to prescribe and comparing this with actual nurse prescribing behaviours during the early years of the legislation. The paper fills a knowledge gap and provides baseline data analysis for subsequent research. Nurses' opinions were collected during the period they were preparing themselves for prescribing. That data was compared with data on the character and extent of nurses' actual prescribing practices over the first two years of implementation. The study showed the number of nurse prescriptions increased. Comparing the first and second years of nurse prescribing, the number of nurse independent prescriptions more than doubled. Over the same period, the number of nurse supplementary prescriptions increased almost six-fold. The implementation of nurse prescribing has increased the scope of nursing care, especially in the treatment of the infections, pain and chronic conditions in the elderly.

Development and regulation of advanced nurse practitioners in the UK and internationally

The NHS in the UK is under increasing pressure as a result of financial and recruitment issues, as well as an ageing population. Nursing has continued to adapt to this challenging time. Over the past few years, the advanced nurse practitioner (ANP) role has been implemented widely in primary and secondary care. However, the ANP role has lacked consistency in scope of practice, training and regulation. This article summarises the development of the ANP role in the UK and internationally, and issues relating to regulation. Globally, ANPs are regulated by one of three different bodies: nationally by central government or a professional body, or locally by employers. In the UK, the role is regulated by local procedures, relying on employers to make decisions about the scope and preparation for practice. Some of the challenges in the UK in relation to ANP regulation are discussed, including variations in scope, organisational constraints and lack of support. These challenges are exacerbated by a lack of role clarity, thereby indicating there is a need to improve regulation of ANPs. The Royal College of Nursing has responded to these challenges by introducing 'credentialing', a system for recording qualifications, skills and experience, but the uptake of this process is yet to be evaluated. Therefore, employers and ANPs should be aware of their collective responsibility for ensuring appropriate role regulation.

LEGALIZATION OF NURSE PRESCRIBING OF MEDICATION IN BRAZIL: HISTORY, TRENDS AND CHALLENGES

ABSTRACT This study aimed to identify the legal and normative contours of nurse prescribing of medications in Brazil, showing its history, trends and challenges. It is an exploratory study conducted through desk research of nursing law, the Health Ministry and the health sector norms to address this issue. The steps of a documentary study and the analysis of data contents were followed. The nursing discipline contributed to the legalization of prescription, but not to its legitimacy; this assignment in primary care is consolidated through protocols and legislation, although there is no clear strategy for monitoring by the Health Ministry; there is resistance in some norms within the health sector. We conclude that there is a trend of nurse prescribing of medication, which currently remains only as a legality, and the main challenge is to achieve legitimacy.

The value of nurses’ tailored communication when discussing medicines: Exploring the relationship between satisfaction, beliefs and adherence

Numerous studies of various populations and settings link patient–provider communication or beliefs to medication adherence. A better understanding of this interplay may help to improve patient-centred communication. To predict adherence, this study used the Beliefs about Medicines Questionnaire and indications of the quality of the nurse’s communication in terms of patient satisfaction. Patient satisfaction with the information provided and the degree to which the information was tailored to them were related to adherence via the patient’s beliefs. This study supports the argument that tailoring is an effective strategy for improving adherence via beliefs and can contribute to medical education and to adherence interventions.

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

Background

Safe and timely access to effective and appropriate medication through primary care settings is a major concern for all countries addressing both acute and chronic disease burdens. Legislation for nurses and other professionals allied to medicine to prescribe exists in a minority of countries, with more considering introducing legislation. Although there is variation in the range of medicines permitted to be prescribed, questions remain as to the contribution prescribing by nurses and professionals allied to medicine makes to the care of patients in primary care and what is the evidence on which clinicians, commissioners of services and policy makers can consider this innovation.

Methods

A integrative review of literature on non-medical prescribing in primary care was undertaken guided by dimensions of health care quality: effectiveness, acceptability, efficiency and access.

Results

19 papers of 17 empirical studies were identified which provided evidence of patient outcome of non medical prescribing in primary care settings. The majority were undertaken in the UK with only one each from the USA, Canada, Botswana and Zimbabwe. Only two studies investigated clinical outcomes of non-medical prescribing. Seven papers reported on qualitative designs and four of these had fewer than ten participants. Most studies reported that non medical prescribing was widely accepted and viewed positively by patients and professionals.

Conclusions

Primary health care is the setting where timely access to safe and appropriate medicines is most critical for the well-being of any population. The gradual growth over time of legislative authority and in the numbers of non-medical prescribers, particularly nurses, in some countries suggests that the acceptability of non-medical prescribing is based on the perceived value to the health care system as a whole. Our review suggests that there are substantial gaps in the knowledge base to help evidence based policy making in this arena. We suggest that future studies of non-medical prescribing in primary care focus on the broad range of patient and health service outcomes and include economic dimensions.

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.

Nurses' use of computerised clinical decision support systems: a case site analysis

AIMS AND OBJECTIVES

To explore how nurses use computerised clinical decision support systems in clinical practice and the factors that influence use.

BACKGROUND

There is limited evidence for the benefits of computerised clinical decision support systems in nursing, with the majority of existing research focusing on nurses' use of decision support for telephone triage. Research has suggested that several factors including nurses' experience, features of the technology system and organisational factors may influence how decision support is used in practice.

DESIGN

A multiple case site study.

METHODS

Four case sites were purposively selected to provide variation in staff experience, technology used and decisions supported by the technology. Data were collected in each case site using non-participant observation of nurse/patient consultations (n = 115) and interviews with nurses (n = 55). Data were analysed using thematic content analysis.

RESULTS

Computerised decision support systems were used in a variety of ways by nurses, including recording information, monitoring patients' progress and confirming decisions that had already been made. Nurses' experience with the decision and the technology affected how they used a decision support system and whether or not they over-rode recommendations made by the system. The ability of nurses to adapt the technology also affected its use.

CONCLUSIONS

How nurses use computerised decision support appears to be the result of an interaction between a nurses' experience and their ability to adapt the technology to 'fit' with local clinical practice.

RELEVANCE TO CLINICAL PRACTICE

One of the stated aims of introducing computerised decision support systems to assist nursing practice is to reduce variation and/or the number of errors associated with clinical practice. The study found unanticipated uses in such systems such as the routine over-riding of recommendations which could lead to an increase rather than a decrease in variation or errors.