An Evaluation of the Expansion of Nurse Prescribing in Scotland

CHAPTER TEN CONCLUSIONS AND RECOMMENDATIONS

Introduction

10.1 This study provided an evaluation of the extension of nurse prescribing following the introduction of new legislation on 2001, as well as touching upon the opening up of the BNF formulary in 2006. The evaluation used surveys, case study and other approaches with nurse prescribers, students on nurse prescribing courses, other health professionals, stakeholders, course tutors and the public. It analysed a wide range of data that provided, within various limits, a significant and at times in depth insight into the development and working of nurse prescribing in Scotland.

10.2 The study clearly shows that the development of nurse prescribing in Scotland since 2002 has been a positive one in a wide range of respects. From the data analysed as part of the study, nurse prescribing expansion has benefited patients, the public and health care professionals in many ways. These benefits include improving patient access to treatment, enhancing patient care, maintaining and improving patient experiences, enhancing professional satisfaction and application of nurse skills, building inter-professional working, enabling effective use of medical staff time, and maintaining public health standards.

10.3 The study showed that for nurse prescribers, regardless of their setting, the expansion appears to have succeeded. However, the depth and breadth of that success varies and the study identified some obstacles that may restrict the successes of nurse prescribing in the future. Such variations may partly relate to institutional and resource factors and partly to personal and professional attitudes and organisational factors. The evidence indicates that in some settings, nurse prescribing could be rolled out even further and have a greater beneficial impact on patients, their carers and health professional and administrative teams if some of the obstacles were removed, if best practice could be more readily exchanged and if communications and support networks could be further facilitated.

Findings: Nurse Prescribing in Practice

Patient Care

10.4 Patient care had been improved by nurse prescribing, particularly in specialist areas and areas of particular competence. The public generally showed considerable confidence in the nurse prescribing processes that they experienced.

10.5 Nurse prescribing made patient care both quicker and easier. Patients placed more value on getting appropriate and effective care than on the qualifications of the person providing the care. Patients also found benefits through better inter-professional liaison about their care and tended to prefer team working rather than autonomous practice. Patients receiving 'complete packages' of care, particularly patients with complex health needs who required daily care, found additional benefit from nurses prescribing. This also benefited carers.

10.6 Respondents felt that patients benefited when nurses' skills in assessment, observation and diagnosis were improved as a result of learning to prescribe.

10.7 Nurse prescribers identified improved consultation skills and contact opportunities to educate patients and promote health as well as to discuss aspects of medication such as side effects and correct administration of treatments like asthma inhalers. This it was felt contributed to improved patient self-care abilities especially in mental health. Nurses' familiarity with medication developed through more careful use of the BNF together with practice in writing prescriptions.

10.8 Nurse prescribers' public health contributions were recognised by medical and nursing staff. The benefits to infection control and better treatment of conditions without the use of anti-microbial drugs or with more careful targeting of microbial drugs were also recognised. Nurses felt that they had further and more expanded roles, for example in smoking cessation and sexual health areas.

10.9 The evaluation found that there was however patchy geographical or professional implementation of nurse prescribing.

Professional impacts of nurse prescribing

10.10 The professional benefits associated with nurse prescribing related to increased satisfaction, improved professional development and a related increase in professional recognition and respect. Benefits were seen to be contingent on CPD, support and resources, including allocated time for studying, ongoing support and education and budgetary resources.

10.11 Effective support for nurse prescribers included informal colleague support, information from and close working with pharmacists, and positive GP/medical feedback. Pharmacists and health service managers generally found nurse prescribing of benefit to practices and patients. Respondents felt that it ensured a more rapid accessible service for patients with certain conditions.

10.12 Some hospital doctors and GPs championed both current nurse prescribing and its extension because of benefits for the public, the NHS, application of nurse skills and workloads across several groups. Rural GPs found major benefits to manageable workloads through the expansion of nurse prescribing.

10.13 Hindrances to nurse prescribing practice often centred on administrative issues, including budget and budgetary allocation issues which resulted in major delays in receiving prescription pads and difficulties with prescriptions not being computerised.

10.14 The medical profession generally found the extension of nurse prescribing to be safe, of benefit to patients and to themselves.

10.15 Nurse prescribers reported that their work had reduced doctor's workloads, but at the same time concerns were expressed about increased workloads for nurse prescribers.

10.16 Nurse prescribers had some fears about nurse prescribing becoming 'overly medicalised' and felt it important to retain traditional nursing roles in future prescribing developments.

Management and co-ordination of nurse prescribing

10.17 There sometimes appeared to be a lack of a coherent, integrated and stable Board level infrastructure for prescribers. In some instances, it was felt that this demonstrated a slow response to the prescribing agenda. Linked to this, some stakeholders perceived a lack of a joined up approach running from the Scottish Government, through NHS Boards and down to the prescribers themselves. Some NHS Boards lacked any leads or had leads only for some sectors. Some stakeholders identified a lack of strategic leadership to carry through prescribing in under-developed midwifery and mental health areas.

10.18 The collaboration between post holders at NHS board level, such as medical directors, directors of pharmacy and lead nurse prescribers was vital, but at times it was felt this was lacking. To some, it appeared that nurse prescribing especially outwith the primary care sector was still on the margins of the administrative system.

10.19 Systems for reviewing and monitoring prescribing practice across Scotland appeared to be assumed, but not always tested. In addition, there was no obvious and suitable medicines management system in place to track the costs of prescribing accurately and document any related benefits.

10.20 The need to have CPD to ensure prescribers' fitness for practice was identified by respondents. 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 supplemented with CPD opportunities at key intervals.

Findings: Nurse prescribing Education

10.21 The most important aspect of the courses according to the focus group participants, was that it enhanced the course members' professional knowledge and expertise. The second most important feature of the courses was that it enabled them to acquire a systematic understanding of pharmacology. This it was felt, increased patient safety and facilitated communication with doctors and pharmacists. Thus, based on the course members' point of view, the courses was felt to be 'fit for purpose'.

10.22 The courses presented a generic model of nurse prescribing and taught a broad underpinning knowledge of pharmacology. Whilst there was evidence that some nurses expected a much narrower course of training, focused on the contexts in which they worked and limited to the actual drugs they would be prescribing, the evaluation found strong reasons for retaining the generic structure. These included preparing nurses to deal with patients with multiple illnesses and supporting the trend towards collaborative practice. Additionally, course members valued the opportunity provided by the generic nature of the course to network with nurses from other specialties, which enhanced their capacity to work collaboratively.

10.23 Mentoring was largely viewed positively, however there were cases of both nurses and mentors who found it extremely difficult to get any allocated time for mentoring. Mentors also reported difficulties in knowing what was expected of their role. Suggested solutions included the use of two mentors: one clinical and one nurse prescriber who had experienced the prescribing course.

NURSE PRESCRIBING POSITIVES AND CHALLENGES

The Positives

10.24 The research indicates that nurse prescribing and the extension of nurse prescribing are working well in a range of settings with regard to a number of factors:

• Nurse prescribers themselves found the educational preparation for the role demanding but effective and fit for purpose.
• The benefits of mentoring, formal and informal, were very positively viewed in the case studies.
• Nurse prescribers found their prescribing work made them more effective as nurses, utilises their skills, enhanced team working and assists patients to obtain more rapid treatment along with high quality care.
• The majority of views expressed by non-prescribing nurses were in favour of nurse prescribing.
• An incidental benefit of nurse prescribing was that it fostered greater collaborative working between professions, and there was a close working relationship between nurses and pharmacists.
• Pharmacists and health service managers generally found nurse prescribing of benefit to practices and patients and ensured a more rapid accessible service for patients with certain conditions.
• The contributions that nurse prescribers could make to public health were recognised by medical and nursing staff. The benefits to control of infections and the better treatment of conditions without the use of anti-microbial drugs or with more careful targeting of microbial drugs were also recognised albeit with some qualifications by some GPs.
• The medical profession generally found the extension of prescribing to be safe, of benefit to patients and to themselves in terms of making their own workloads more manageable. Some hospital doctors and GPs were strong champions both of current nurse prescribing and of nurses developing further in this field in the future. They saw a whole range of benefits for the public, the NHS, application of nurse skills and workloads across several groups.
• Rural GPs found major benefits in managing high workloads through the expansion of nurse prescribing. The nurse prescribers reduced the GP prescribing workload.
• The public generally showed considerable confidence in the nurse prescribing processes that they experienced. Such findings have been born out by the nation-wide omnibus studies.

The Challenges

10.25 The research indicates that nurse prescribing and the extension of nurse prescribing are working well in a range of settings however there are a series of challenges including:

• The administrative delays in processing prescription pads immediately post qualifying for nurses resulted in some unnecessary long delays in enabling nurse prescribers to prescribe.
• Concerns about increased workloads on nurse prescribers exist. This was linked to the phenomenon of potentially moving high caseloads around from one professional group to another without addressing underlying staffing issues.
• A small number of non-prescribing nurses expressed concerns about the risk of potential errors because of relative inexperience of nurse prescribers compared with GPs and medics.
• There has been patchy geographical or professional implementation of nurse prescribing and this has a health care equity dimension.
• The informal networks to support nurse prescribers through nursing, medical and pharmacy colleagues worked well. However, the perceived wishes of nurse prescribers for continuing professional development and ongoing support need to be addressed in some way.
• In addition, the value of internal local, regional and cross-Scotland networks for exchanging information about best practice and remedies to professional, administrative, budgetary and other issues is substantial. As nurse prescribers grow both in numbers and activity, the need for such effective infra-structures will be sharpened.
• With the expansion of prescribing not only to nurses but other allied health professionals, the 'mentoring needs' will grow and mechanisms should be put in place that recognise and reward these roles and ensure they are fit for purpose.
• There appears to be a lack of a coherent, integrated and stable board level infrastructure for prescribers and, in some instances, there have been slow response of NHS Boards to the prescribing agenda.
• Linked to this, various stakeholders perceived a lack of a joined up approach running from the Scottish Government, through the NHS Boards and down to the prescribers themselves.
• There appears in part to be a fragmentation of nurse prescribing policy, implementation and management is a cause for concern in some NHS Boards although it is gradually being addressed. Some NHS Boards lacked any leads or had leads only for some sectors.
• Some stakeholders identified a lack of strategic leadership or champions to carry through prescribing in such areas as midwifery and mental health, which are seriously under-developed.
• Demonstrated and regularly reviewed and monitored good governance applied to nurse prescribing practice across Scotland appeared to be assumed and not tested.
• The collaboration between post holders at NHS board level, such as medical directors, directors of pharmacy and lead nurse prescribers is vital, but may at times be lacking as may be effective management systems. To some, it appeared that nurse prescribing especially outwith the primary care sector is still on the margins of the administrative system.
• There was no obvious and suitable medicines management system in place to track the costs of prescribing accurately and document any related benefits.
• Access to detailed and specific data related to numbers, location and type of prescribers and activity levels is either currently limited or lacking.

RECOMMENDATIONS AND SUGGESTIONS FOR FUTHER RESEARCH

10.26 The research team suggest the following recommendations around nurse prescribing in practice:

• Further development and underpinning of appropriate nurse prescribing support and networking groups is needed;
• Prescription pads should be made available to nurse prescribers in a timely manual and delays in issuing replacement pads should be addressed;
• Computerisation of prescriptions, lack of access to a patients prescription records (prescriptions from other healthcare professionals) and poor IT provision in areas of the NHS (and do not just apply to nurses) could be addressed;
• Additional information/education for GPs about the particular nature of nurse prescribing in primary care and how it may benefit their practices could be provided;
• Where appropriate, patchy geographical and/or professional implementation of nurse prescribing chould be addressed;
• Coherent, integrated and stable board level infrastructure for prescribers could be implemented in all Board areas.
• 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 Scottish Government, through the boards and down to the prescribers themselves would offer many benefits;
• Close collaboration between post holders such as the Chief Medical Officers and Chief Pharmacists and lead nurse prescribers should be encouraged and linked to effective management systems;
• Nurse prescribing especially out with the primary care sector should be fully supported by administrative systems;
• Fragmentation of nurse prescribing policy, implementation and management in some boards should be addressed including ensuring leads are in place for all prescribing professional groups;
• Board level administration to track nurse prescribing perhaps through a part-time post would bring benefits.
• The role of Community Health Partnerships could be enhanced as it 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 needed; and
• Suitable medicines management systems, if they do not already exist, to track the costs of prescribing accurately and document any related benefits would also bring significant benefits.

10.27 The research team also suggest the following recommendations following the research around the nurse prescribing courses of preparation:

• Courses should make their requirements explicit to students, especially where the course involves a low ratio of on-site to off-site study;
• The courses should continue to treat nurse prescribing generically, providing a systematic coverage of pharmacology and a full range of the nurse specialties represented on each course. Best practice in meeting the needs of specialists within the generic framework should be shared between centres.
• Whilst different universities should be free to develop their provision in ways that meet the needs of their particular intakes, curriculum development projects should be undertaken at a national level to create a body of educational practice and curriculum materials on which course leaders could draw as appropriate. These resources could underpin the cumulative development of the courses and guard against the loss of expertise when key members of course teams leave. This work could usefully concentrate on the following:

• Materials for pre-course preparation;
• Ways of customising the course to the needs of different specialities;
• Pedagogic techniques for meeting the learning needs of mature course members who are anxious about the academic study of pharmacology, portfolio writing and formal examinations after a long period away from study;
• Further articulating the generic model of nurse prescribing as the underpinning for all nursing prescribing practice, and as a common reference point for the different parts of the course;
• How to facilitate and assess the compilation of a personal core formulary within a generic course, and how to incorporate this learning experience in a comprehensive nurse prescribing curriculum;
• Course-specific assessment techniques, including the possibility of constructing a question bank for access by all the courses; and
• Course-specific formative evaluation techniques.

• Internal course evaluations should include anonymous course member evaluation instruments which cover the issues of course quality identified in the focus groups and this should be monitored by NES.
• Closer liaison is needed between NHS Boards and some course providers to ensure that the course rationale is fully understood by the former and a need for a planned admission process with sufficient advance notice to course leaders;
• Services need to ensure that nurse prescribing practices are underpinned by adequate clinical governance and the courses should refer to this;
• The PDPs of nurses who have completed the course in nurse prescribing should include plans for relevant CPD and this should be arranged by the services concerned;
• Nurse prescribing training, CPD and updating should be enhanced and include protected time for private study in addition to the time they are given for attending course contact days, ongoing support and education, and budgetary resources be made available;
• The issue of allocated time with designated mentors needs to be addressed (Designated Medical Practitioner DMP). One solution proposed related to nurse prescribers in training having two mentors: one clinical and one nurse prescriber who had experienced the course; and
• Changes in the education of nurse prescribers may impact on service delivery and subsequent uptake of courses. There should be adequate consideration and funding for the backfill of nurses undertaking prescribing training.

10.28 The following areas, in the opinion of the research team, are worthy of further and fuller or new investigation.

• Further research would enhance the evidence base and ensure better informed decision-making, review and policy development in the prescribing field;
• Further detailed analysis of nurse prescribing in Scotland from a health economics perspective to identify what is being prescribed, where and at what cost;
• Analysis of the scope of competence of individual nurse prescribers;
• Nurse prescribing errors should be investigated in the context of how all health professionals are now prescribing;
• How nurses assess and use information on pharmaceutical products and where they obtain such information merits investigation in terms of impacts on practice;
• 'Patient education' by nurse prescribers about drug usage and management of conditions should be investigated and compared with medical practices and case studies of outcomes from the 2 groups if they work in different ways;
• A number of nurse prescribers saw benefits in relation to patient safety because they believed newer prescribers would perhaps be more cautious than those who have been prescribing for lengthy periods. This should be researched; and
• Self-prescribing and internet prescribing by patients should be reviewed in the context of their impact on all prescribers' practices (medical, pharmacist and nurse), public health and patient safety.

10.29 There is a high level of agreement between patients, the public, nurse prescribers, physicians and other health professionals and health managers about the benefits of nurse prescribing to patients. However, some organisational and procedural challenges remain to ensure the maximum effectiveness of prescribing is fully achieved. Evidence indicates that in some settings nurse prescribing could be rolled out even further and have a greater beneficial impact if some of the obstacles were removed, if best practice could be more readily exchanged, and if communication and support networks could be further facilitated.