An Evaluation of the Expansion of Nurse Prescribing in Scotland

CHAPTER FIVE: STAKEHOLDER PERSPECTIVES

Introduction

5.1 This chapter explores stakeholder perspectives on nurse prescribing and draws on the rich qualitative data generated in the stakeholder interviews and case studies.

5.2 The first set of interviews with stakeholders (See Annex 17) provided valuable insights into their views of current nurse prescribers' practice and how this might develop in the future. The challenges and opportunities of nurse prescribing were also explored with interviewees. A second set of stakeholders were interviewed as part of the case studies (See Annex 13) which included a wide range of health professionals including doctors, nurses and pharmacists, groups representing patients and trade unions.

Views from general stakeholders

Administration and IT issues

5.3 Questions were raised about the challenges of operationalising nurse prescribing. Many stakeholders expressed concerns about the infrastructure needed to deliver the type of nurse prescribing they wished to see. These concerns related to IT matters and to the lack of an effective electronic script record system. Some of these concerns, albeit never so strong as to indicate major weaknesses in the whole prescribing process, also emerged in the case studies and have clearly persisted for several years.

Educational needs

5.4 Views about educational needs were implicitly polarised. One school of thought saw nurse prescribing boundaries limited only by the boundaries of competent and effective nursing care. This required nurse prescribers to be drawn from a cadre of nurses with significant knowledge of pharmacology and wide experience who would be trained to take prescribing decisions across the BNF limited only by 'nursing care' boundaries. The other school of thought appeared to focus on breadth and not depth with more nurses taking on 'lower level' nurse prescribing roles.

5.5 A view was expressed that there was a need to have CPD and updating to ensure prescribers' fitness for practice. Contradictory views were expressed about the need for personal formularies and for generic versus specific courses. However, among the stakeholders, the overwhelming consensus was for a generic course with CPD offering an opportunity to focus on specific types of prescribers and their needs at a later date.

Team Working

5.6 Nurse prescribers and indeed all other prescribers rely to a greater or lesser extent on team working. This may be with other non-prescribing nursing colleagues, pharmacists, health service managers and with those operating IT systems. Many professional and patient group stakeholders noted that nurse prescribing depended on effective team working between health professionals and paradoxically noted that the very act of nurse prescribing would enhance team working between nurses, doctors, pharmacists and other health professionals. Some professional stakeholders advocated wider joint training on prescribing between, for instance, nurse prescribers and pharmacists who would be issuing scripts.

Patient safety

5.7 All stakeholders believed that patient safety was paramount in the introduction and extension of nurse prescribing. How exactly this was to be operationalised and audited was not always clear. However, no general or specific threats to patient safety were identified as long as training, mentoring and good governance were in place. Further exploration of these findings are included in chapter 9.

Impacts on patients

5.8 Stakeholders representing nurse prescribers, non prescribing nurses, medical staff, pharmacists, patient and professional groups all spoke of the benefits that they perceived had flowed, and would flow, from nurse prescribing to patients. These benefits include improved access to a range of health care professionals, continuity of care, rapidity of prescribing, patient education. These data are further detailed in chapter 7 which discusses patient perceptions and benefits.

Impacts on nurses who prescribe

5.9 All stakeholders, from medical, nursing and other health professional groups through to groups representing patients with particular conditions saw benefits for nurses who prescribe through:

• Expanded roles using and extending skills
• Greater variety in jobs
• Improved relationships with doctors and others in medical teams
• Greater awareness of prescribing budgets and value of timely interventions

5.10 Nurse stakeholder groups saw drawbacks linked to the limits in the formulary from which nurses could prescribe. This meant that nurses had to go back to doctors to sign off scripts that they themselves could have safely and competently prescribed.

5.11 All stakeholder groups saw various challenges in:

• CPD within nurse prescribing;
• Mentor and safety net development to support nurse prescribers;
• Resources and time to maintain and expand roles in both the primary and acute sector;
• Equity issues for nurses who prescribe in relation to those who do not - this relates to several Agenda for Change issues with regard to 'specialist' nurses;
• Development of effective protocols to guide prescribers, review systems and audits;
• Risks of nurse becoming mini pharmacists/mini GPs;
• Ending of blame culture with regard to prescribing errors; and
• Inter-professional working with doctors and pharmacists and AHPs - specifically shared patient care responsibility across all the above groups.

Impact on medical staff

5.12 Most medical and nursing stakeholder groups considered that nurse prescribing was of benefit to GPs and would be of greater benefit in the future. This related to 'doctor light' activities which meant that GPs would need to spend less time on 'simpler' cases that would now be tackled by nurse prescribers and so have more time to spend on complex cases. Doctors also considered that prescribing would increase team work in practices and enhance the role of nurses, further drawing on their experience and skills. These elements would again benefit the GP. Some saw an important need for education of GPs on the changing roles of nurses to reduce potential resentment at their expanded prescribing roles. Others flagged the need for effective protocols, administrative and IT controls on prescribing for both doctors and nurses. Several stakeholders feared that prescribing budgets could prove unmanageable without new or better procedures in place to oversee them.

5.13 For hospital doctors, the benefits related to the recognition of nurses' existing role in prescribing, in terms of reducing demands on SHOs when prescribing requirements and practice were well understood by nurses. As protocols were better established in hospitals, several stakeholders saw the extension of nurse prescribing in this sector as less problematic. However, again paradoxically, some saw the current nurse prescribing role in hospitals as limited and less challenging than it should be.

5.14 Certain stakeholders considered that the competence and skills of nurse prescribers were much more likely to be used less well than in primary care: for them it threatened to be a missed opportunity to extend the formulary. Some stakeholders noted possible confusion for patients and carers about who had responsibility for the patient: the doctor or the nurse. Ambiguity about roles was, therefore, an issue.

Health Board Governance

5.15 A range of stakeholders noted the following:

• The patchy geographical or professional implementation of nurse prescribing and the health care equity dimension of this. Specifically nurse prescribing could play a role in addressing the health inequalities experienced by vulnerable and hard to reach groups such as travellers, migrant workers, homeless people and drug users;
• The lack of a coherent, integrated and stable board level infrastructure for prescribers and, in some instances, the slow response of NHS Boards to the prescribing agenda. Each board needed professional and managerial champions for nurse prescribing and local strategies and team working at a lower level on prescribing practice;
• A joined up approach to nurse prescribing was needed involving the Scottish Government, NHS Boards and down to the prescribers themselves. The lead nurse prescriber network was felt to have helped to achieve this and should continue;
• Close collaboration between post holders at NHS Board level, such as medical directors, directors of pharmacy and lead nurse prescribers was felt to be vital but may at times be lacking as were effective management systems. To some, it appeared that nurse prescribing, especially outwith the primary care sector, was still on the margins of the administrative system;
• The fragmentation of nurse prescribing policy, implementation and management was a cause for concern in some NHS Boards although it was gradually being addressed. Some NHS Boards lacked any leads on nurse prescribing policy or had leads only for some sectors;
• The need for board level administration to track nurse prescribing perhaps through a part-time post. If, within NHS Boards, the selection of and support for nurse prescribers was not carefully and properly done, the resource will be wasted and the opportunity to enhance patient care and nurse skills could all too easily be lost. Stakeholders felt that the opportunity provided by the development of the role of Community Health Partnerships should be seized upon to expand the opportunities for nurse prescribing in certain budgetary areas;
• The lack of strategic leadership or champions to carry through prescribing in such areas as midwifery and mental health which were seriously under-developed was a major concern;
• The need for demonstrated and regularly reviewed and monitored good governance to apply to nurse prescribing practice across Scotland. and
• The need for suitable medicines management systems to be put in place to track the costs of prescribing accurately and to document any related benefits.

Views of health staff on nurse prescribing

Nurse/pharmacist interactions

5.16 Pharmacy and nurse stakeholder groups commented on their relationship and the importance of team working. For some, the relationship between the nurse prescriber and pharmacist was critical. This related to information and advice from the pharmacist especially to the novice nurse prescriber, their mutual interest in patient care, the need for or benefits of, joint education programmes for both professional groups who would carry forward prescribing in the future.

5.17 Governance, IT, ethical and audit questions were raised by many pharmacists. A particular issue related to the need for pharmacists to know what prescribing powers a particular nurse prescriber had and hence for pharmacists to understand the different types of nurse prescriber that they would come into contact with.

Stakeholder views from case studies

Benefits to practice

GP/Hospital based medical staff views

5.18 GPs found benefits from nurse prescribing in relation to areas where nurses were knowledgeable and skilled, particularly in the areas of dressings and catheters within general practice. Nurses often had a better understanding of the appropriateness, cost and usefulness of products in these areas and therefore it was sensible and convenient for nurses to prescribe independently without having to seek authority from GPs or hospital based medical staff. In community midwifery too, there were benefits where treatments such as Gaviscon and Iron were well within the nurse prescribers' remit;

"Main expectation is that they would prescribe in areas that they have an experience that we don't have in. I mean the classical ones are dressings and catheters. We get asked to prescribe things and we haven't really much knowledge of the different dressings and far less of the costs or usefulness or appropriateness of them and we're, in that respect we're just like monkeys, we just sign a prescription because its 12 dressings and we don't really know if they are appropriate or relevant". ( GP)

5.19 Hospital based medical staff found that nurse prescribing within specific competency areas enhanced care;

"My perception in the past is that patients have gone home with medication that hasn't been up-titrated. I've met patients in clinic a month after going home and asked them about medication and it's not changed. I think the real strength of the system is that patients are being assessed in a focused way; the medication is being reviewed and up-titrated appropriately…it's made me feel happier about patients being at home. It's made me feel happier about patients being reviewed regularly with somebody who takes a keen interest in this area". (Hospital Consultant)

Practice manager views

5.20 Patient care has been maintained and streamlined with nurse prescribing and the quality of patient care was not necessarily affected.

Pharmacist views

5.21 Pharmacists' experiences were largely positive with references made to the demonstrated competence of NPs and their good knowledge base, particularly within areas of expertise;

"Nurses have their own area of expertise and they have proven that they know what they are doing. If they have done the appropriate CPD, they have done the appropriate training…G.P.s are generalists, they have a lot of different talents. Nurses obviously do as well but they tend to be more specialised". (Pharmacist)

Recognition, rewards and roles

GP/hospital based medical staff views

5.22 Some nurse prescribers reported initial worries about the legalities of nurse prescribing. For example, in one setting (case study one) GPs wrongly perceived that they would be accountable for nurse prescribing errors in practice. Most of these worries were addressed by a locality manager who was able to 'educate' the GPs on the different issues involved, including the benefits of nurse prescribing to practice, the legalities and requirements for supervision. This suggests that medical concerns may partly be based on a lack of information about nurse prescribing in practice.

5.23 Some GPs predicted increased spending from nurse prescribing. This linked to a general questioning of nurse prescribers' awareness of the budgetary constraints compared to GPs, particularly with the recent development of costly antibiotics. One GP also thought that asthma clinics cost more if run by nurse prescribers rather than GPs.

5.24 Some GPs were also concerned that nurse prescribing would move away from specific areas of competence and into general areas where the GPs believed nurse prescribers were under-trained in diagnostic practice.

5.25 Some GPs were troubled that nurse prescribers would fail to keep up to date with prescribing practice and questioned whether there was any appraisal system for prescribing post-qualification.

Non-prescribing nurse views

5.26 Nurse prescribers may be more likely to make mistakes than GPs because of their relative inexperience in prescribing. In addition, nurse prescribers may not be prescribing regularly and therefore may be more likely to make a mistake or be less aware of side effects than someone who is a regular prescriber of medication.

5.27 Reflecting some nurse prescriber views, non-prescribing nurses were concerned that nurses were taking on more and more roles without getting the appropriate financial recognition for these roles. This was seen as a potential area of exploitation;

"I think we're quite good at taking on lots of other roles and they're not always rewarded financially or seen in the same line as a G.P. or doctor or whatever. I think nurses like to see things through, they like to give the best service…There's always a fear that nurses become used because nurses are always keen to extend their knowledge for the benefit of their patients". (Community Nurse)

5.28 However, it was acknowledged that this would not deter non-prescribing nurses from taking the prescribing course in the future.

Support in Practice

Pharmacist views

5.29 A few pharmacists described the introduction of systems for auditing and checking prescriptions given by nurse prescribers. For example, a system had been set up to record the prescriptions that had been dispensed and were to be collected by nursing staff for patients, as previously there had been difficulties identifying which nursing team was responsible for collecting individual prescriptions. The new system provided clarity.

5.30 Accident and Emergency had set up their own audit trail with the pharmacist carrying out regular checks of nurse prescribing records and a similar system had been set up with the community hospitals pharmacist. This was helpful to nurse prescribing in the sense that any aspects of practice that could be improved upon were reported back to nurse prescribers and hence practice developed.

Hindrances to practice

GP/hospital based medical staff views

5.31 GPs were aware of the issue of time delays in nurses receiving their prescription pads and reported effects on the nurse prescribers' enthusiasm. One GP (case study 1) also suggested that the potential nurse prescribing benefits for GPs were not fully realised because of prescription pad delays. For example in a recent case of terminal care the nurse prescriber still needed to involve the GP because of the prescription pad issue.

5.32 Some GPs and hospital based medical staff highlighted their ignorance of who was prescribing within the nursing team. Hence skills and areas of expertise in prescribing could be under utilised or missed. It was mooted that nurses and medical staff met up to review who was actively prescribing and the areas of nurse prescriber competence. Mutual benefits could be gained in terms of GPs and hospital based medical staff being able to use nurse prescribing expertise and nurse prescribers being able to utilise medical knowledge in areas of practice that they wished to develop.

Pharmacists' views

5.33 Practice-based pharmacists (case study 3 -case study 3) felt that nurse prescribers were being 'overly cautious' - more so than GPs - because of a lack of confidence. One pharmacist within case study 2 reported that practice nurse prescribers had been more hesitant with prescribing medication such as antibiotics, than they have with products and applications such as dressings;

"We're now starting to see the extended part of the nurse prescribing …what I'm getting from some of the nurses is that they're a little bit slow at wanting to do antibiotics. They don't mind doing dressings and things but forget antibiotics and things…but they're starting to come through that now so we've seen quite a few antibiotics along with the dressings.

Inter-relationships between Health Professionals

Practice Manager Views

5.34 One practice manager (case study 1) felt that relations between nurses and GPs had become more distant with the increase in nurse prescriber autonomy. Nurse's reliance on GPs in the past for authorising prescriptions was viewed as having a positive impact on relations and team working because daily contact between professions was inevitable;

"I think it's maybe changed their relationships a little bit in that they're more, I don't know, midwives in particular are very much more independent of the GPs than they were a few years ago. You know, it was very much more maybe the GPs leading things and the midwives sort of standing beside them but now I would say in ante-natal care it is the midwives who are leading the care without any question and the GPs are there for backup and I think prescribing has probably contributed to that".

Pharmacist views

5.35 Nurse prescribing has positively helped pharmacist-nurse relations. The introduction of nurse prescribing heightened the contact that pharmacists have with nurses, which strengthened working relationships between professions.

5.36 Pharmacists reported that their knowledge was being more widely used with the introduction of nurse prescribing. Nurse prescribers asked pharmacists' advice within everyday practice. Pharmacists reported that GPs and hospital based medical staff were less likely to consult pharmacists when making prescribing decisions;

"…I think it's opened up my role whereas a doctor wouldn't come to you for advice…but nurses are always open to suggestions because they are now learning this new role so they will come and ask…so they are always open to more communication than a doctor. A doctor tends to present the prescription, that's it done, whereas before some prescriptions are done the nurse will phone along to say 'what's available'? 'where's this, where's that'"?

Summary and conclusions

5.37 In general, there was a high degree of concordance and general optimism expressed by all stakeholder groups and case study participants interviewed about their support both for current nurse prescribing, its benefits to a wide range of groups and its further development. A small number of GPs in the case studies expressed far greater reservations about nurse prescribing than the national medical stakeholder groups.

5.38 Significantly, medical groups often fully supported the continued extension of nurse prescribing and the philosophy underpinning that extension whereas some, but not all, nursing stakeholders expressed concern and caution about particular developments and future strategies. These latter concerns related primarily to issues surrounding the resource and funding capacity of the NHS in Scotland and the commitment of health professional groups to roll out nurse prescribing steadily, where competent and experienced nurses were involved, to cover a Nurse Prescribers Formulary ( NPF), drawing on all of the British National Formulary ( BNF), appropriate to the delivery of high quality nursing care.

5.39 The case studies and linked logs have provided the fullest qualitative picture of nurse and midwifery prescribing at work from the perspective of nurse prescribers, GPs, hospital doctors, pharmacists, non-prescribing nurses, managers, patients and carers.

5.40 The stakeholders and case study participants did identify some problems and some missed opportunities. These related to opportunities to expand the role and skills of nurse prescribers, to offer greater variety in nursing roles, to improve team working among health professionals, to ensure timely interventions and to enhance the quality and speed of the patient journey. A number of relatively simple administrative, budgetary, support and policy changes discussed within the chapter would ensure benefits for all involved in nurse prescribing.

5.41 Perceived benefits to practice of the extension and development of nurse prescribing in Scotland by all groups interviewed in the case studies far outweighed the perceived difficulties. Support in practice for nurse prescribers varied and may play a large or small part in positively or negatively impacting on the implementation and operation of nurse prescribing in the country.