An Evaluation of the Expansion of Nurse Prescribing in Scotland

EXECUTIVE SUMMARY

Main Findings

• The expansion of nurse prescribing has benefited patients, improved public health and benefited health care professionals in many ways.
• These benefits include improved patient access to treatment, enhanced patient care, maintaining and improving patient experience, enhanced professional satisfaction and application of nurse skills, building inter-professional working, enabling effective use of medical staff time, and maintaining public health standards.
• Although nurse prescribing and its expansion appear to have succeeded the depth and breadth of that success varies and the study indentifies some obstacles that may restrict the successes of nurse prescribing. Such variations may be partly due to institutional and resource factors as well as 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 professionals and administrative teams 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.
• Nowhere in the survey, case studies or stakeholder interviews were any nurse prescribing incidents or problems reported that affected patient safety. However, stakeholder groups, the health professionals themselves and their managers all identified the need for effective education, supervision and auditing of nurse prescribing work.
• For senior managers, this was viewed as an essential part of effective clinical governance. How extensive and exactly how effective such governance of nurse prescribers is may require further research.
• The capacity to demonstrate good governance at all levels and locations of nurse prescribing would provide important and necessary re-assurance for the prescribers themselves, the other health professionals they work with, the patients and public at large, user stakeholder groups and the Scottish Government.

Introduction

1. Nurse prescribing first became part of the UK government's policy agenda following the Cumberlege Report ( DHSS, 1986). By 2001, nurse prescribing was extended to include more nurses and to cover a wider formulary. Nurse prescribers in Scotland can now prescribe a range of controlled drugs for specific medical conditions.

2. This research project provides an evaluation of the extension of prescribing powers to nurses following the introduction of new legislation in 2001 and aimed to examine:

• The implementation and operation of the extension of nurse prescribing;
• The impact of nurse prescribing on the appropriate use of nurses' skills;
• Patient benefit from nurse prescribing and patients' perceptions of their experiences of care;
• The impact of nurse prescribing extension on workloads;
• The extent to which public health and patient safety are safeguarded; and
• Different approaches to nurse prescribing training.

Methods

3. A variety of methods were used to achieve the project objectives across two main areas of evaluation: nurse prescribing in practice and preparing for prescribing. The evaluation of nurse prescribing in practice included:

• Stakeholder interviews and meetings;
• A postal questionnaire of all nurses Nursing and Midwifery Council database who prescribe;
• Two surveys of the public;
• Case studies involving nurse prescribers across acute and primary care settings, patients, other health professionals and managers using in depth interviews across Scotland.

4. The exploration of nurse prescribing education also used a mixture of methods including:

• Documentary analysis;
• A questionnaire;
• Interviews; and
• Focus groups supplemented by case histories and diaries.

Findings: Nurse prescribing in practice

Patient Care

5. 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.

6. 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.

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

8. 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.

9. 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 found that they had further and more expanded roles, for example in smoking cessation and sexual health areas.

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

Professional impacts of nurse prescribing

11. 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.

12. 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.

13. 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.

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

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

16. 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.

17. 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

18. There sometimes appeared to be a lack of a coherent, integrated and stable Board level infrastructure for prescribers. In some instances, it wad 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.

19. 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.

20. 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.

21. 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

22. 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'.

23. 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.

24. 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.

Conclusions

25. 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 eschanged, and if commincation and support networks could be further facilitated.