An Evaluation of the Expansion of Nurse Prescribing in Scotland

CHAPTER THREE : METHODS

Introduction

3.1 This chapter describes the research methods employed in this study and some of the methodological thinking behind the choice of the key methods used during the different stages of the project. It also describes the ethical and governance approvals and structures within which the research operated.

3.2 Nurse prescribing has in recent years been researched using a range of methods. These have included qualitative, quantitative and mixed methods and data gathering tools such as questionnaires, interviews, focus groups and participant observation. These methods individually and together have different strengths and weaknesses. In the initial planning for this study, the focussed literature review described in Chapter 2 was used extensively to inform what methods should be used.

3.3 A variety of methods were then selected to achieve the project objectives (see Chapter one) 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 nurse prescribers on the Nursing and Midwifery Council database;
• Two surveys of the public;
• Case studies involving nurse prescribers, patients, other health professionals and managers using in depth interviews across Scotland.

3.4 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 followed up.

3.5 The sections below provide a brief explanation about each of the methods used, why they were selected and how they were used in terms of sample and settings.

Methods used to evaluated nurse prescribing in practice

Stakeholder interviews and meetings

3.6 The first method used to evaluate nurse prescribing in practice was stakeholder interviews and meetings. Interviews were semi-structured and were primarily but not exclusively telephone interviews, lasting an average of 45 minutes. The groups and individuals initially contacted fell into four categories listed below. At least two interviews were conducted with representatives in each of the following groups:

• Patient and public-oriented interest groups e.g. Diabetes UK;
• Professional bodies e.g. Nursing and Midwifery Council;
• Representative bodies e.g. Royal College of Nursing; and
• Key individuals' e.g. Scottish Government Lead for Nurse Prescribing.

3.7 Stakeholders were interviewed about their involvement, past and present, in nurse prescribing in Scotland; and their assessment of the benefits and disadvantages of nurse prescribing for the NHS Scotland to date in terms of impacts on patients, on nurses, on GPs and hospital doctors, on allied health professionals ( AHPs), practice managers and others.

3.8 The stakeholders were also questioned about how they hoped and expected nurse prescribing to develop over the next 5 years and whether they would like to see activity develop. A copy of the stakeholder semi-structured interview schedule can be found in Annex 17.

Survey research with the general public and current nurse prescribers

3.9 A representative sample of the Scottish population was asked about nurse prescribing at two stages in the project. In addition all nurses who were registered as nurse prescribers in Scotland were given an opportunity to take part in a quantitative survey.

Surveys of the public's attitudes to nurse prescribing

3.10 The views of the public on nurse prescribers, and their experience of nurse prescribing, was elicited twice during the project (during September 2004 and February 2007) through a Scottish omnibus survey of adults aged 16 and over. The surveys were conducted across representative sample of Scottish cities, towns and villages

3.11 Questions were commissioned at the start of the project to provide data on public perceptions of current nurse prescribers. The same questions were used again in the second survey (a full copy of the questionnaire can be found in Annex 2). Questions included in the survey examined respondents' experience of nurse prescribing in relation to:

• Location of prescribers;
• Satisfaction of those receiving a prescription from a nurse;
• Reasons for satisfaction and dissatisfaction with nurse prescribing; and
• Benefits of nurse compared to doctor prescribing.

The 2004 sample involved 1,016 respondents, 1,000 of which had had a doctor's prescription and 120 (12%) had had a nurse's prescription. These were stratified by age, sex and socioeconomic group. The 2007 survey involved 1,007 respondents, 978 (97%) of which had had a doctors prescription and 160 (16%) had received a nurse's prescription. The numbers of respondents in both surveys with experience of nurse prescribing was small therefore findings relating to these surveys must be treated with caution.

Survey of existing nurse prescribers

3.12 A survey (copies of the full questionnaire are available in Annex 1) of nurse prescribers in Scotland on the professional registers in 2003 was carried out and captured:

• Who the nurse prescribers were (geographical location, practice setting age, gender etc);
• Where they were based;
• How long they had been qualified;
• How long they had worked as a nurse prescriber;
• What type of practice they worked in;
• Why they continue/ceased working in the field;
• What their work experiences were; and
• How they worked with colleagues and other health professional groups.

3.13 The questionnaire was despatched to 3,700 nurse prescribers in Scotland at the end of May 2005. A total of 948 completed questionnaires were returned representing a response rate of 26%. This survey provides the best statistical picture of nurse prescribers and their practice in Scotland at a particular time. However the response rate does not allow strong statistically significant results to be drawn from the data set. The responses provide useful information about many aspects of nurse prescribing. The findings informed later stages of the project particularly the case studies e.g. by determining topics to be covered as part of the case studies with staff and patients.

3.14 The survey returns reflected the particular prescribing base at the time: namely community based nurses working in a particular setting with a specific type of role and prescribing training. The nature and number of nurse prescribers now at work has changed substantially but, as later case study materials indicate, many of the attitudes, opinions, opportunities and problems identified by the prescribers in 2005 remained the same throughout the study.

Case studies

3.15 Following on from the survey research came a number of case studies (see Annex 15). The case studies tracked a sample of nurse prescribers, their patients and carers, GPs and pharmacists, other health professionals working with nurse prescribers in a representative range of settings and with a range of prescribers.

3.16 Six case studies were conducted in two NHS Board areas. Each site was chosen as it linked to particular nurse prescribing activity or likely challenges for nurse prescribers in practice. Case study sites included general practice teams, an Accident and Emergency (A&E) centre, a community hospital, nurse specialists e.g. cardiac rehabilitation, and covered primary and secondary care. The general practices were selected from an inner city, a large town in a rural area and a village. General practices included training and non-training practices, large practice teams and single handed GP practices. Key participants in the other case study sites varied. Where necessary carers or relatives could be interviewed instead of or in addition to patients i.e. where patients were unable to give consent or were incapacitated. As the study progressed, additional nurse prescribing groups in mental health and paediatrics were targeted and included in the case studies.

3.17 The case studies provided the principal qualitative means to examine the impact of nurse prescribing on nurses' skills, patient safety, public health, tasks and workload; on patients and their relatives or carers, on other nurses and on GPs, hospital doctors, pharmacists and others. They provide important information and insights into nurse prescribers' roles and impact on such topics as patient empowerment, encouraging patient adherence and wider health promotion matters. They offered insights into some aspects of nurse prescribers' clinical reasoning and decision-making through a number of routes e.g. health professional and patient, to build up a full picture of the prescribing process and outcomes as possible in the practice setting.

Site selection and participant recruitment procedure

3.18 The overall site selection and data collection approach in the case studies within two NHS Boards was in three phases:

• In phase 1 access issues were negotiated with relevant individuals in both of the Board areas e.g. Board Nurse Directors. Following overall governance and ethical approval for each NHS Boards, Directors of Nursing, Leads for Nurse Prescribing and relevant managers were contacted to inform them about the evaluation and to ask for their assistance in phase 2 and 3 of the study.
• Phase 2 involved collection of data on nurse prescribing activity within the two Board areas which culminated in the selection of case study sites. As part of this, a nurse prescribing activity questionnaire and invitation to participate in case studies were sent to all nurse prescribers across the two Board Areas. In order to maximise the response-rate, the activity questionnaire was anonymous and participants were not asked for any personal information. If the nurse prescribers were willing to receive more information and be contacted about taking part in a case study, they were asked to return a reply form. This asked for details relating to their nurse prescribing activity and contact information. The rationale for sending the invitation to all nurse prescribers within the chosen Board area was to 'over-recruit' so that the opportunity for choice in relation to the selection criteria was maximised.
• Phase 3 identified those who had provided details of prescribing activity and individuals who matched the agreed criteria for the case studies and inviting them to participate (see Annex 16).
• Selected nurse prescribers were then contacted, sent the detailed information about the case studies and asked to return a signed consent form if they were willing to take part (see Annex 7 and 10). When a consent form was returned, the researcher contacted the participant to establish their participation. Once nurse prescribers were identified and a case study site agreed other key participants e.g. patients, medical practitioners were identified by the nurse prescriber and invited to take part in the case study by the researcher. Others with indirect involvement in Nurse Prescribing were also identified e.g. non-prescribing nurses, pharmacists, carers, service managers and team leaders along with key stakeholders such as senior managers and nurse prescribing leads.

Methods of data collection

3.19 The case studies involved several methods of data collection including semi structured interviews and activity logs (see Annex 8 to 15).

Semi-Structured interviews

3.20 Semi-structured interviews were used to explore data arising from the activity questionnaires and activity logs. The interview schedule can be found in Annex 12. Interview themes were chosen to represent the main areas of interest to the evaluation and the overall project objectives. Such general themes and questions were adapted and made specific to the different participant groups' involvement with/interest in nurse prescribing.

3.21 Semi structured interviews were also used with patients and stakeholders (see Annex 13). Interviews were conducted with the patients and carers of these independent, extended and developing supplementary prescribers (see table 3.2). Managers, pharmacists and medical staff were also interviewed for the case studies (see table 3.2).

Table 3.2 Interviewee categories and numbers

Interviewee Categories	Numbers
Patient (including one who was also a carer)	15
Case study stakeholders	3
Medical staff	6
Managers (one of whom was a doctor)	3
Pharmacists	5

3.22 Patients were recruited from a range of condition categories e.g. Cardiology, Diabetes, Asthma. The nurses interviewed in practices or hospital settings who were not nurse prescribers worked with nurse prescribers. Nurse prescribers, nurses, GPs, pharmacists and practice managers sometimes but not always came from the same team.

3.23 The data analysis of the case studies and other interviews used thematic content analysis. Reliability was maintained by 3 analysts from different disciplines and professional fields reading all the transcripts and carrying out analysis. A modified Delphi approach was used whereby analysts both met and emailed to discuss and prioritise emerging themes.

Activity logs

3.24 Nurse prescribers participating in the cases studies were asked to keep a log of their activities for 2 weeks in order to build a picture of 'real-life' working practice. This provided valuable insight into the nature and overall pattern of nurse prescribing activity, with particular reference to non-prescribing outcomes as well as instances when an item had been prescribed (See Annex 8 and 9).

3.25 This type of design was considered to be particularly suited to evaluation of nurse prescribing as the frequency and nature of prescribing activity may vary considerably across different roles and areas of practice.

Evaluation of nurse prescriber education

3.26 When the research was conducted, training in nurse prescribing in Scotland was provided in seven Scottish university schools/departments of nursing and midwifery. The courses were based on a common outline curriculum, including the same set of nurse prescribing competencies and a requirement of 26 days study and 72 hours of supervised learning in practice. All the courses were part-time and blended different modes of learning: attendance at the university, private study, access to e-based materials and supervised learning in practice. However, within this framework the courses were of different lengths (varying from 11 to 23 weeks ⁴) and they delivered the 26 days study through different ratios of on-site to off-site learning. These differences reflected the diverse needs of the course members, especially those in remote areas for whom a greater proportion of the course would most appropriately be delivered by distance learning. This part of the study used a variety of methods to determine:

• How effective courses in nurse prescribing education were as a preparation for course members' future roles as nurse prescribers;
• Course member views on the most and least effective aspects of the course;
• In what ways could the provision be improved; and
• What problems course providers faced in bringing course members up to the required level of achievement.

3.27 The evaluation included 97% of the 186 course members who began these courses between 12 January and 26 May 2005. Participants were given information on the project ( Annex 4) and asked to complete a consent form ( Annex 5). Data were collected by a combination of methods:

• Analysis of course documentation - course programmes and resource materials;
• An initial questionnaire survey of course members to ascertain their professional and educational background, the clinical situations in which they would use their training, the amount of protected study time awarded by employers, etc (See Annex 3);
• Interviews with course providers - this encompassed 10 course leaders/ associate leaders and 10 lecturers in pharmacology, covering all 10 centres (See Annex 6); and
• Group work (including the use of nominative techniques ⁵) was conducted with course members at the end of the course to explore the positive and negative aspects of the course in preparing them for future practice.

3.28 Following data collections outlined above, comparisons were carried out of the provision at the 10 centres. These compared the ratio of on-site to off-site study, the detailed course content, the schedules of assessment, the duration of the courses and the quality assurance procedures using documentary comparison of course documents/timetables. Differences in approach were discussed with the course leaders who have shared best practice and developed their courses further as a result of collaboration within their professional network ⁶.

3.29 The courses were also then assessed in terms of their fitness for purpose. The purposes of the courses were articulated in relevant policy documents, in the nurse prescribing competencies, in the NHS Education for Scotland guidelines (see http://www.nes.scot.nhs.uk/prescribing/index.html ) and in expressions of individual learning needs by the nurses who attended them. The extent to which the courses met these purposes was assessed by a thematic analysis of both the interviews with course providers and the course members' focus groups, triangulated where possible with the results of the initial survey.

3.30 As the University of Stirling Department of Nursing and Midwifery, delivered one of the courses under evaluation, a 'firewall' was constructed between the educational evaluation team (based in the University's Institute of Education) and those members of the Department of Nursing and Midwifery who were involved with the Stirling course: the latter had no access to data collected on the courses. This ensured that the interpretation of the data collected relating to the course was conducted independently of the Stirling course team. Validity checking was however undertaken within the 'firewall' before the final report was generated.

Ethical and governance issues

3.31 The research team worked within the research governance and ethical frameworks of the NHS and Universities that operate in Scotland especially those relating to informed consent. The research recognised the need to have clear boundaries of consent and confidentiality in project work to fulfil all requirements of the 1998 Data Protection Act. Ethical considerations required sensitivity about the concerns and feelings of the nurse prescribers and other stakeholders, timing of interviews, use of logs, and issues of confidentiality in relation to the research. Confidentiality was assured throughout the research process and anonymity was preserved where agreed and appropriate systems put in place to support this e.g. Nurse prescribing leads distributed board level questionnaires and case study reply slips to preserve anonymity of participants. Participation in the study was within the context of informed consent. Appropriate ethical approval, as required, at various stages of the research was obtained through the Central Office for Research Ethics Committee ( COREC) (now the National Research Ethics Service NRES) and the University's ethical committees. For reasons relating to complexity and the additional scrutiny required at ethical committees, children under 16 were excluded from the research study.

3.32 The project was overseen by an in-house (University) steering group that met regularly over the life of the project, and involved lay and professional members as appropriate to that steering group. This group reported to and consulted at regular intervals throughout the research with a Research Advisory Group established by the Scottish Government.

3.32 Copies of the study instruments, for example forms, information sheets, tools, logs, matrices and questionnaires used are located in the annexes at the end of the report. (See Annex 1 to 17).