An Evaluation of the Expansion of Nurse Prescribing in Scotland

CHAPTER EIGHT: NURSE PRESCRIBING IMPACT ON HEALTH SERVICE ORGANISATION

Introduction

8.1 This chapter looks at the impact of nurse prescribing on health service organisations. It explores the telephone interview with stakeholders from government agencies, NHS Boards, from the case studies, and from the survey of nurse prescribers (2005 detailed in chapter 3 and 4). Anonymised stakeholder responses, where appropriate, are included. The questionnaire, case studies, interviews and educational evaluation provided the means for following up and testing of many of the topics raised in these initial stakeholder interviews. It also draws on the data from ISD outlined in table 1.2.

Impact on workloads

8.2 In all six case studies some GPs and hospital-based doctors reported either reduced workloads or the potential for reduced workloads due to nurse prescribing. Nurse prescribers reported increased satisfaction from prescribing but, in some instances, noted an increased workload and greater pressure. For mental health nurse prescribers, workloads increased at the start of nurse prescribing practice, particularly when setting up clinical management plans. However, it was felt that there had not been any lasting effects on workload.

8.3 Mental health nurse prescribers also considered that nurse prescribing had taken some pressure away from the consultant and perhaps GPs. Some pharmacists also reported increased workload as there was now more dialogue and consultation with nurses about prescribing issues, however these pharmacists considered that relationships had improved and that this was having a positive impact on patient outcomes.

8.4 Nurse prescribers within the case studies completed activity logs for 2 weeks prior to interview. These identified prescribing patterns for each nurse prescriber, and activities related to prescribing. Overall, nurse prescribers took increased opportunities to offer advice on for example, the side effects and correct administration of medication to patients at the same time as prescribing. They were conscious of cost implications, in particular the availability of over the counter medications and advised patients to purchase such medications rather than prescribe for these items. Their prescribing habits demonstrated a breadth of knowledge and skills in consultation, assessment, diagnosis, patient education and writing and revising prescriptions.

8.5 Depending on individual roles, they used their wider prescribing powers to prescribe a range of medications - commonly prescribing analgesics, antimicrobials where appropriate, and items for chronic disease management such as asthma, and health promotion such as smoking cessation. For example, one nurse prescriber in a community setting undertook 186 consultations over a 2 week period, and chose to prescribe in only 76 of these cases, using the opportunity to advise, refer or arrange follow-up in other cases. Another nurse prescriber in a remote and rural community setting undertook 6 consultations and prescribed for 3 - in each case this was for products relating to skin and wound management. Workloads varied but it is clear that nurse prescribers did not always choose to prescribe if medication was not appropriate, instead offering advice or referring on.

8.6 Nurse prescribers reported that GPs and hospital based medical staff had noted that nurse prescribing reduced their own workload but often seemed unaware of how. For example they were unaware of what and how much was being prescribed by nurse prescribers. Others discussed the benefits in relation to their own workloads;

"Being a single handed GP it enables me to feel more open to discuss …the therapeutic management of patients ….. it supports my role in that taking some of the workload off".

8.7 One GP suggested that nurse prescribing may have impacted on the workload of reception staff in the sense that they may have less work to do in relation to processing prescriptions for GPs to sign. Other GPs and hospital based medical staff felt that workloads could be more effectively distributed amongst nurses in accordance with who can/can't prescribe within the team, rather than having a random distribution of workloads.

8.8 GPs also suggested that nurse prescribing in areas of expertise would lead to more accurate prescriptions from pharmacists because nurse prescribers would be more knowledgeable about the correct amounts or sizes of products needed, this was particularly pertinent for wound dressings. This could reduce returned item numbers for pharmacists. However, there may be increased workload for pharmacists with regard to resolving issues in relation to the way that prescriptions are produced, to ensure that prescriptions are written in such a way that they reflect quantities available. For example 'one box' may be interpreted as one box containing 10 dressings, or maybe one box (or carton) containing ten individual boxes.

8.9 Some practice managers discovered that a "huge volume" of work was taken away from GPs in the health promotion field especially in smoking cessation when nurse prescribers took up this work. Non-prescribing nurses additionally felt that nurse prescribing had increased nurses' approachability and therefore their workloads. This was related to public perceptions of nurses being less busy than GPs and perhaps more approachable for prescriptions;

"You know, going to a GP for contraception is maybe that bit more scary than... you know the midwife… at lunchtime the school kids and things used to come to the health centre, so they may ask for contraception".

8.10 An increase in telephone calls to midwifery for patient advice was also highlighted by non-prescribing nurses (case study 1). Such calls were not always midwifery-related and were becoming more widespread as people realised that there were prescribers within the team.

8.11 The above section illustrates that nurse prescribing has had an impact on workloads across health organisations both in primary and secondary care for the nurse prescribers themselves as well as pharmacists and doctors. This has led to a rebalancing of workload with implications for the staff involved. It has also lead to an increased need for advice and support for those taking on new roles.

Nurse and medical staff views of nurse prescribing

8.12 The overall picture that emerges on staff views of nurse prescribing is one of consensus between the two professional groups around the positive and mutually beneficial development of nurse prescribing in Scotland. Some nurses were threatened by the new developments but most welcomed them. A small number of nurses worried about the training and competence of their nurse prescribing colleagues but most identified benefits to nurses and patients. There were contradictory fears that extensions of nurse prescribing would lead to nurses over-reaching themselves and losing the 'caring' role distinctiveness of nurses by becoming junior doctors. These de-skilling worries were balanced by other groups of nurses and stakeholders who wished to see the extension of nurse prescribing across the formulary with nurses using all their skills to the full that their training and knowledge had equipped them with.

8.13 Most medical practitioners, in primary and secondary care settings, welcomed the development of nurse prescribers and noted benefits to patients and health service benefits in terms of use of time, resources and skills. A small number of GPs were reluctant to act as mentors to nurse prescribing students. An equally small number of physicians doubted the competence of nurse prescribers particularly with regard to 'diagnosis' and in terms of extending the formulary for instance to anti-biotic drugs. Some of these issues are discussed in greater detail in Chapter 9. One specific problem that emerged with regard to the extension of nurse prescribing related to the apparent lack of knowledge that some GPs had about which nurses were prescribers and what they did. Better communication and CPD within practices should remedy this problem relatively easily.

8.14 Findings on inter-professional working have been detailed in earlier chapters and there was a surprisingly high degree of professional agreement about the benefits accruing from inter-professional working. The working relationships between nurse prescribers and pharmacists appeared to be especially good as was the relationship between cardiologists and nurse prescribers. There was some evidence that the relationship between medical consultants and specialist nurses who prescribed was very positive.

8.15 This would suggest that nurses and medics across NHSScotland's organisations have for the most part sees nurse prescribing as a positive step forward. There are however issues which could be addressed such as better communications with GPs regarding nurse prescribing.

Promoters and barriers to change

8.16 Nurse prescribers had been highly motivated to become prescribers because of the activity's contribution to the improvement of patient care (2005 survey of existing nurse prescribers). [This was seen as a 'very' or 'quite' significant factor in their decision to become a nurse prescriber amongst 92% of respondents. Whilst improved patient care was listed as the primary motivator in becoming a nurse prescriber, a large proportion thought that the opportunity for continuing their professional development was a 'very' or 'quite' significant factor influencing their decision. 85% of respondents felt that job satisfaction was a significant factor behind their decision whilst only a half said that an improvement in their job prospects was a significant reason for becoming a nurse prescriber. Employer pressure was the least significant aspect on respondents' decision to become nurse prescribers.

8.17 The snapshots of two NHS Boards in 2005/6 also provided some information about health service organisation issues affecting both the numbers and range of activities of nurse prescribers. Of 14 NP responders in one board, around 80% were prescribing and 20% were not. For whatever reason, this indicates a loss of one fifth of the qualified prescribers in a small cohort of 14. Movement of staff into new posts or other workplaces where prescribing does not occur may explain for instance some of these figures. Better selection of staff for such training and a clearer understanding of where and how they may prescribe might contribute to a reduction in this wastage.

8.18 Numbers of prescriptions issued do not necessarily provide indicators of either the extent or effectiveness of nurse prescribers nor do they indicate consultations where prescribing was not needed. However, in the two NHS Boards, the nurse prescribers who responded to our requests for information indicated the following prescription practices in a typical week in a range of clinical settings (see table 8.1).

Table 8.1 Prescriptions issued by nurse prescribers per week in 2 NHS Boards

No. of prescriptions issued per week	NHS Board 1	NHS Board 2
	%	%
Under 5	20	70
6 to 10	20	10
11 to 20	20	10
21 to 40	27	0
41 and over	13	10
Total	100	100

8.19 The survey of nurse prescribers in 2005 also revealed that 60% of those prescribing wrote between 2 and 10 prescriptions in an average week, with 23% writing less than this and 15% more (See table 4.3 Chapter 4).

8.20 78% of survey respondents said that they prescribe in their current job. This was higher amongst those working in health centres and GP practices (87%) than in other areas.

8.21 Extended and Supplementary Prescribers tended to write more prescriptions on average than Independent Prescribers. 35% of Extended and Supplementary Prescribers wrote 11 or more prescriptions in an average week, compared with 8% of Independent Prescribers.

Chart 8.1 Average number of prescriptions written in a week

8.22 Peer support and an opportunity for informal discussions about prescribing may be an important factor in maintaining and extending the competence and confidence of nurse prescribers especially new prescribers. Delays in registration as prescribers and delays in receiving prescription pads, has impacted on the confidence of some prescribers and may inhibit future prescribing. Such support could come from day to day contact with colleagues or informal and formal networks. GPs and physicians will also play an important role in such a mentoring process and in maintaining good practice. As the numbers of nurse prescribers increases, these networks and supports within the nursing profession will increase. Data indicate that in many clinical settings, there are currently relatively few nurse prescribers working with more than one other nurse prescriber. Board and division-led networks for prescribers are important in ensuring professional support and development of nurse prescribing and communication linked to the work of 'lead' prescribers'.

Table 8.2 Working pattern of nurse prescribers in 2 NHS Boards

Number of NPs in team	NHS Board 1	NHS Board 2
	%	%
1 to 2 NP's	50	50
2 to 5 NP's	38	36
6 to 10 NP's	12	0
Over 10	0	14
Total	100	100

8.23 A significant number of nurse prescribers surveyed in these two boards were working alone or with one other colleague. However, almost all these nurse prescribers would have been working with and been supported by medical and pharmacy colleagues and, as more nurse prescribers qualify, the numbers of nurse prescribers working on their own will diminish further.

8.24 Critical to the effectiveness of nurse prescribing and indeed to the effective use of NHS resources is that trained nurse prescribers do prescribe. A range of reasons for non-prescribing were identified in our national survey of nurse prescribers, stakeholder interviews and case studies. Apparently 'simple' bureaucratic reasons applied in a number of cases. These included;

"Hospital trust has still not sorted out prescription pads etc, for supplementary prescribers"

"Awaiting prescription pad". Or "Haven't yet received prescription pad".

"I have been employed in a management position for 4 months therefore don't prescribe"

"Although recently registered with NMC (April 06') have still not received prescription pads and confirmation from manager of agreement to prescribe"

"Hospital protocol not complete"

"Dispensing surgeries until very recently did not have access to patient notes. (Paper or electronic)"

8.25 Processing the registration and recognition of nurse prescribers rapidly within NHS Boards, statutory and professional bodies should resolve such issues easily.

8.26 There were also a range of clinical and managerial factors at work.

These included;

"No patient group directions in our ward and there is only 1 nurse prescriber in our hospital"

"Course provided foundation, and I am now working to develop knowledge i.e. chemotherapy and supportive care"

"Not required in post"

"Lack of experience"

"Dispensing GP practice in this community; surgery staff are reluctant to dispense my prescription - awaiting an update on practice"

"I work 1 day a week and the occasion hardly ever arises where I need to prescribe"

"Prescription pad identifies only GP practice in small area"

8.27 These raise larger questions about the rationale for health service organisations selection of nurses to attend nurse prescribing courses in terms of what they do, what they could do and what the service wants them to do. The obstacles also raise questions about career developments of nurses and perhaps the capacity and commitment of individual nurse prescribers to take forward their work in this field. Incentives such as recognition through 'Agenda for Change' may also help this.

Summary and conclusions

8.28 The extension of nurse prescribing in Scotland has created new opportunities and challenges not just for the nurse prescribers but also for other in their organisations such as health professionals and managers. Selecting, training, managing and supporting nurse prescribers and responding to changes in clinical practice, pharmaceutical developments and patient and public demands and expectations have all placed demands on health services. Workloads of the key health players have changed because of nurse prescribing although they have not necessarily increased. Patients have experienced better and quicker prescribing but this may have also resulted in increased patient demands and expectations. Better use of staff skills and, often their time, appear to have resulted in improved patient care.

8.29 Evidence suggests that nurse prescribing has been both effective and efficient without any huge surge in drug budgets, unnecessary prescribing or threats to public health or patient safety (discussed in detail in chapter 9). All these elements must benefit health service organisation and are well received by patients and, according to the omnibus surveys, by the public.

8.30 Inter professional collaboration and team working also appears to have been enhanced by the process of nurse prescribing and as the activity is bedded in and rolled out further, any major fears about such prescribing appear to have abated. The operationalisation of nurse prescribing has run into a small number of bureaucratic and attitudinal snags. The former should be easily and quickly addressed within the health service; the latter may take longer to resolve. The network of lead nurse prescribers in the NHS Boards has allowed important support, information and good practice exchanges to operate. At times this has been both formal and informal and there are benefits to be gained for the health service from supporting both networking approaches.

Recommendations

• Further initiatives would develop CPD, support and address time issues, including allocated time for studying, ongoing support and education and budgetary resources
• The potential for and benefits to be gained from the further development and underpinning of appropriate nurse prescribing support and networking groups is considerable
• The delays in receiving prescription pads affect the capacity and confidence of nurse prescribing.
• Difficulties with non-computerisation of prescriptions are critical for some nurse prescribers. These difficulties also potentially adversely affect patient safety linked to the lack of access to a patients prescription records (prescriptions from other healthcare professionals). The causes relate to poor IT provision in areas of the NHS (and do not just apply to nurses).
• Additional information/education for GPs would be beneficial about the particular nature of nurse prescribing in primary care and how it may benefit their practices
• There is patchy geographical and/or professional implementation of nurse prescribing. This has a health care equity dimension. Nurse prescribing could play a role in addressing the health inequalities experienced by vulnerable and hard to reach groups.
• There appears to be a lack of a coherent, integrated and stable board level infrastructure for prescribers. In some instances, there has been a slow response of boards to the prescribing agenda. Boards could identify professional and managerial champions for nurse prescribing and local strategies and team working at a lower level on prescribing practice.
• A joined up approach running from the Executive, through the boards and down to the prescribers themselves would appear to offer many benefits. The lead nurse prescriber network has already helped to achieve some of these benefits.
• Close collaboration between post holders such as the Chief Medical Officers and Chief Pharmacists and lead nurse prescribers is vitally important and could be linked to effective management systems. To some, it appeared that nurse prescribing especially out with the primary care sector is still on the margins of the administrative system.
• The fragmentation of nurse prescribing policy, implementation and management is a cause for concern in some boards although it is gradually being addressed. Some boards lacked any leads or had leads only for some prescribing professional groups.
• Board level administration to track nurse prescribing perhaps through a part-time post would bring benefits. If, within boards, the selection of and support for nurse prescribers is not carefully and properly done, the resource will be wasted and the opportunity to enhance patient care and nurse skills can all too easily be lost. Seizing the opportunity provided by the development of the role of Community Health Partnerships may be critically important in terms of expanding the opportunities for nurse prescribing in certain budgetary areas.
• Further developments of strategic leadership and champions to carry through prescribing in midwifery and mental health which are seriously under-developed would be worthwhile
• Demonstrated and regularly reviewed and monitored good governance related to nurse prescribing practice across Scotland is critical
• Suitable medicines management systems, if they do not already exist and we could identify none in our research, to track the costs of prescribing accurately and document any related benefits would also bring significant benefits
• CPD and updating will ensure prescribers' fitness for practice. Contradictory views were expressed about the need for personal formularies and for generic versus specific courses for particular courses. However, among the stakeholders, the overwhelming consensus was for a generic course with CPD offering an opportunity for focus on specific types of prescribers and their needs at a later date.