An Evaluation of the Expansion of Nurse Prescribing in Scotland

CHAPTER SIX : NURSE PRESCRIBING EDUCATION

Introduction

6.1 This chapter presents the findings from the evaluation of the educational provision for nurse prescribers (termed 'programmes of preparation') in Scotland. This element of the research aimed to describe and evaluate the different approaches to nurse prescribing and examine the learning experience.

6.2 The evaluation involved:

• A description and analysis of the different nurse prescribing courses provided in Scotland;
• A survey of the nurses undertaking the courses to establish a profile of the course members, the clinical situations in which they intended to use their training and the time allowed by employers to undertake the courses;
• Interviews with course providers (See Annex 6); and
• Group meetings with course members to seek their views of the courses.

6.3 The survey of all nurse prescribers in Scotland in 2005 ( chapter 4) and stakeholder interviews (chapter 5) both also explored aspects of nurse prescriber education. The case studies ( chapter 5) also included interviews with newly qualified nurse prescribers.

6.4 The scope of the evaluation was comprehensive, surveying all 7 courses that commenced in Scotland in the first half of 2005. One university offered the course at 2 locations and another at 3 locations. Therefore a total of 10 centres throughout Scotland were included in the evaluation. ⁸ Further details of the methodology used in this element of the research is described in chapter 3.

Description of the nurse prescribing courses

6.5 Data for this element of the research were collected from the course documentation and additional information was supplied by the course leaders.

6.6 At the time the research was conducted, nurse prescribing was provided in 7 university schools/departments of nursing and midwifery in Scotland. All courses were based on a common outline curriculum, including the same set of nurse prescribing competencies with a requirement of 26 days study and 72 hours of supervised learning in practice.

6.7 All courses were delivered within the following common framework:

• The NHS Education for Scotland outline curriculum ( http://www.nes.scot.nhs.uk/prescribing/index.html) , including a set of competencies;
• A quality assurance process operating at 4 levels - NHS Education for Scotland monitoring, university external examining, school/department module appraisal, ⁹ internal course evaluation;
• 72 hours of learning in practice, in the nurse's own clinical area supervised by a designated medical prescribing practitioner;
• Common reference material on relevant websites such as the National Prescribing Centre site, the British National Formulary site and the NHS Education Scotland site; and
• Competency-based assessment by means of a portfolio in which the nurse evidences practice by reference to the competencies.

6.8 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.

6.9 However, within this framework the courses differed in terms of length of the course (varying from 11 to 23 weeks ¹⁰) and in the proportion of the 26 days study delivered as on-site to off-site learning.

6.10 The term 'on-site' meant attending the university for a 'contact day ¹¹' which typically involved a mixture of classroom instruction, tutorial meetings and self-directed study. 'Off-site' meant private study in the workplace or home, using web-based materials, distance learning packs, textbooks, handouts and other materials. Such study was generally supported by ongoing tutorial contact.

6.11 A distinction could be drawn between the courses where the primary mode of delivery was off-site (course members attended the university for 5 or 7 contact days, and spent the remainder learning at a distance) and the courses where the primary mode was on-site (14-25 contact days, with correspondingly fewer days learning at a distance). These were not hard-and-fast categories, because the latter courses differed in the ratio of on-site to off-site study. They also differed by requiring either attendance at blocks of contact days (e.g. 5 consecutive days with several weeks between blocks) or attendance one-day-per-week over a period of several weeks (table 6.1). The courses with a low ratio of on-site to off-site delivery divided into those which relied primarily on web-based materials to deliver instruction off-site and those which relied primarily on hard-copy materials.

Table 6.1 Ratios of on-site/off-site study

Courses
Low ratio of on-site to off-site learning		High ratio of on-site to off-site learning
Web-based distance learning	Distance learning with home study pack	Block attendance for contact days	One-day-per-week attendance for contact days
3 centres, all operated by one university	2 centres, both operated by one university	2 centres	3 centres

6.12 Table 6.1 should not be interpreted as depicting 4 distinct types ofcourse, but as different ratios of on- and off-site learning in a range of courses which share certain common features:

• All the courses blended classroom teaching, web-based learning and private study; and
• All the courses were offered on a part-time in-service basis, and so even those nurses taking a course with a high number of on-site contact days had a significant element of 'distance learning' or study undertaken in personal time.

6.13 The ratio of on-site to off-site learning did not appear to have a significant impact on the learning experience. There was virtually no criticism of the paucity of on-site learning experiences, despite the fact that half the courses provided as few as 5 - 7 contact days. ¹² Evaluative comments centred instead on the quality of the experience, regardless of whether it was on-site or off-site. Nevertheless, many course members apparently received protected study time only for contact days. Thus a nurse attending a course which required only 7 contact days would have less protected study time than one attending a course which required attendance at the university for 25 days.

6.14 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.

The Course members

6.15 All those who began the nurse prescribing courses in Scotland between 12 January and 26 May 2005 were invited to take part in the survey. The following sections provide a profile of the nurses who took part together with details of the amount of protected time given by their employers to complete the course and training, courses of CPD taken to complement the prescribing course and the clinical duties they envisaged performing as nurse prescribers.

6.16 A total of 186 questionnaires were completed, a participation rate of 97%. A copy of the questionnaire used can be found in Annex 3.

Professional Affiliation

6.17 The course members consisted almost entirely of nurses (94%) but there were a small number of midwives and health visitors (table 6.2).

Table 6.2 The course members' professional affiliations

Professional affiliation	%	N
Nurse	92	171
Health Visitor	3	6
Midwife	3	5
Nurse and Midwife	2	4
Total	100	186

Healthcare setting within which the course members practised

6.18 Course members were asked to indicate the setting in which they practised, more than one option could be chosen. Half of the course members (50%) worked in a health centre/ GP practice and just over a quarter in an acute hospital setting (Table 6.3). There were two unanticipated outcomes to this question:

• 14% worked in more than one healthcare setting; and
• many course members selected the 'other' category option.

Table 6.3 Healthcare settings within which the course members were practising*, **

Healthcare setting	%	N
Acute hospital	28	53
Health centre/ GP practice	50	93
Community hospital	10	18
Nursing home	2	3
Other	27	50

* Respondents could choose more than one option.

** Base: All course members 186

6.19 The 'other' categories included: family planning (12), community (11), home visits (4), out of hours service (3) and then one or two individuals for each of ' LCHP', community mental health team harm reduction service, GP lead, hospice, Local Health Care Co-operative, homeless addiction team, community addiction team, patients' homes, substance misuse clinic, District General Hospital, and 'clinics'. One respondent described him/herself as being in ' transition between posts'.

Anticipated prescribing roles and associated duties

6.20 Course members were asked to state the type of prescribing role(s) and associated duties they expected to perform after completing the course. The results indicate that the cohort was diverse and that many of the anticipated prescribing roles quite narrow.

Geographical area of practice

6.21 Course members were asked about the geographical area they worked in, more than one option could be chosen. About half (51%) of course members worked in urban areas and a third (34%) in rural areas. (Table 6.4). Approximately 23% reported that they worked in more than one geographical setting.

Table 6.4 Geographical areas in which the course members practised*,**

Area of practice	%	N
Rural and remote	19	36
Rural	34	63
Urban	51	95
Not stated	4	7

* Respondents could choose more than one option

** Base: All course members 186

Age Profile

6.22 Over two thirds (69%) of nurses being trained as prescribers were over 40 years of age (table 6.5).

Table 6.5 Age distribution of nurses training as nurse prescribers*

Age band	%	N
20-29	3	6
30-39	27	51
40-49	53	99
50-59	16	29
Not stated	1	1
Total	100	186

*Base: All course members 186

Academic Qualifications

6.23 Table 6.6 indicates the highest level of non-professional academic qualification achieved by course members. Over 50% of them possessed a first degree and/or higher degree. Almost 83% had achieved the academic level of Highers or above.

Table 6.6 Highest Non-professional academic qualification*

Highest non-professional academic qualification	%	N
Uncertificated IT training	1	1
Standards/ GCE/ GCSE	9	17
Highers/'A-S' Levels	26	49
Advanced Highers/'A' Levels	3	5
First Degree	42	79
Higher Degree	11	21
Other	1	2
Not stated	6	12
Total	99	186

* Totals may not add up to 100 due to rounding

Complementary CPD courses

Table 6.7 Complementary courses being taken

Course Type	No. taking course
Specialist clinical course	25	Diabetes 9 Cardiovascular diseases 5 Asthma 5 Chronic disease management 3 Acute illness 3
Specialist qualification	6	Nurse Practitioner 5 District Nurse 1
Minor injuries	4
Minor illness OOH	8
Community health	9	Family planning/sexual/reproductive health 4 Travel health 2 Acupuncture 1 Smoking cessation 1 COPD 1
Nurse Triage Diploma	6
Degree in Nursing	8
TOTAL	66

6.24 A majority of course members (61%) reported that they had already completed, were currently taking or were intending to take other CPD courses which complemented the nurse prescribing course they were undertaking.

6.25 Table 6.7 gives the breakdown of the complementary courses that were cited. Some respondents had taken 2 or 3 courses. However, almost half the respondents who said they were taking complementary courses did not give details of them, so the following breakdown is not comprehensive.

Study time

6.26 Course members were asked how many hours their employer gave them off work per week, so that they could take the nurse prescribing course. The results indicated that a very high percentage had been given no additional time off other than the days needed to attend the course (table 6.8).

Table 6.8 Protected Study Time

Hours off work per week	%	N
None other than the course contact days	27	50
Still being negotiated	18	33
Any amount of study time could be taken at the course member's discretion	5	10
A specified period of protected study time Had been allocated	45	83
Item omitted	5	10
Total	100	186

6.27 The number of contact days on the different courses varied between 5 and 25 days. Over a quarter (27%) of course members were not given additional protected time for private study to make up the required 26 days. This figure rose to 45% if those who were still negotiating for protected time when the course started were included. Only 50% of the respondents reported that they had been awarded a definite period of study time. This is a significant finding, especially when considered alongside the views of course members who believed that the greatest weakness of the course was lack of time to study (6.79).

6.28 Further interpretation is limited due to the ambiguities in both the question and many of the responses. Although asked to report the number of hours remitted per week, respondents often reported weekly, fortnightly, monthly or whole-course amounts, and others did not specify the units in which they were measuring the remission. Some of the figures cited could not possibly have been the weekly amount the question requested. Consequently, it is not possible to calculate how much time was protected specifically for private study, but it is clear that the amounts varied widely.

6.29 In addition, whilst a small number of course members were apparently permitted to take as much time off for study as they wished, this did not necessarily mean a reduction in their workload;

"As much as I would like but there be no-one doing my work while I am away. I just have to catch up" (Course Member).

6.30 A nil allocation of time off work to study might not mean that the course member had no time to study. Some part-time employees in this category reported that they were studying in their own time. One course member said that he/she was given no study time because it was not possible to reduce the hours worked, but that he/she would be paid for the extra hours of study.

The course providers' perspective of the nurse prescribing courses

6.31 Data for this element of the evaluation was collected via semi structured interviews with course leaders and lecturers. Ten course leaders/associate course leaders and 10 lecturers in pharmacology ¹³ responsible for delivering the courses at all 10 centres were interviewed. All were sent a list of the issues to be covered in the interviews in advance. In outline, these comprised the following:

• How easy or difficult was it to bring all the course members up to the required standard of competence? The reasons for any difficulties encountered and the actions needed to improve the courses' capacity to bring course members up to the required level;
• The diversity of the intake, how the course was adapted to meet these diversities and the action needed to improve the capacity of the course to accommodate a diverse intake;
• Course members' principal concerns about the course, how the course dealt with them and the action needed to improve the course's capacity to take action; and
• (For course leaders only) The main problems in directing the course, and the action needed to overcome these problems?

6.32 The following themes emerged from analysis of the interviews:

Theme 1: The appropriateness of the generic nature of the outline nurse prescribing curriculum, given the range of nurse specialties now taking the course

Theme 2: Meeting the challenges of teaching pharmacology

Theme 3: Linking the nurse prescribing course with service needs.

The appropriateness of the nurse prescribing curriculum

The need for a generic course

6.33 Perhaps the fundamental question about the course structure was that it was a generic form of provision while the course members came increasingly from a range of specialised clinical backgrounds. Course leaders reported that many course members, especially clinical nurse specialists, arrived with an initial expectation that they would be taught about the prescribing practices in their specialty and the specific drugs they would use.

6.34 This expectation was in line with the specific focus frequently found on in-service courses for health professionals. However, none of the courses were narrowly focused in this way. The approach usually adopted involved:

• Teaching a generic model of prescribing, based on the principles of pharmacology, pharmacy, law etc;
• Teaching foundation knowledge of pharmacotherapeutics with reference to a comprehensive range of drugs, including how to access further information from websites, how to use the BNF, etc; and
• Requiring course members to use this knowledge base to construct their own professional prescribing practices by self-directed study and learning-in-practice.

6.35 Course leaders argued that it was undesirable to abandon the generic model for the following reasons:

a) It would require replacing the existing generic courses with many more specialised ones, many of which would be very narrow:

"If we did that, we would have to have about 20 different courses for each different specialism and that is not possible". Course leader.

b) Given the move towards integrating different branches of the NHS and encouraging 'joined up working' between specialties, professions and departments, the segmentation would be counter-productive:

"More care is going to be delivered in the community so therefore it's important that hospital based nurses have a true understanding of how prescribing happens in the community and vice versa". Course leader.

c) A further argument against highly specialised courses is the incidence of co-morbidity. A safe and competent nurse prescriber needs a broad knowledge of drug treatments:

"… because they may well have a patient that comes to them with multiple conditions and whilst they're going to be focussing on one condition, they've got to be aware of the treatments and how they may impact on each other". Course leader.

d) Finally, including nurses from different backgrounds encourages a beneficial cross-fertilisation of ideas.

"Some of the students, when they come in, want to have 2 groups, primary care and secondary care … and they want to learn together [i.e. within those groups]. However, my experience over the last couple of intakes was [that] the cross fertilisation of learning by mixing up these people has been immense". Course leader.

"The mental health students we've had have found [the generic nature of the course] a particular problem. However, in the last intake, by the end one particular student really had turned that around and found the advantages of being in the wider group, and there are several who have actually commented on how they have learned from each other, even if it's not their area of practice". Course leader.

6.36 This view was strongly endorsed by the course members (paragraphs 6.81 and 6.82). There was a consensus that the most important outcomes of the course included networking with nurses from different professional backgrounds and acquiring a comprehensive knowledge of pharmacology, both of which were believed to increase professional efficacy, and both of which were due to the generic nature of the course.

6.37 Nevertheless, this leaves the problem of ensuring that employers and course members are fully aware of the rationale of the course before they attend it:

"Their expectations of the course are different to what the course delivers. I think that they think we will talk about all of the drugs that they will use and we certainly don't do that". Course leader.

6.38 There thus seems to be a need to improve employers' and course members' awareness of what the course entails, and how it will underpin their future professional development.

Meeting the challenges of teaching pharmacology

6.39 When asked about the course members' concerns, most course leaders said that their greatest concern was the pharmacological content of the course. The pharmacology lecturers agreed with them that the course members found this the most challenging part of the course:

"The pharmacology I think certainly has proved to be the part that has proved the most daunting for the students". Pharmacology lecturer.

"They struggled to understand the pharmacology". Pharmacology lecturer.

6.40 This view was endorsed by the course members' views. While identifying the acquisition of a knowledge base in pharmacology as one of the most important outcomes of the course, they often described the subject as 'difficult'.

6.41 The difficulty appears to arise from 2 sources. The first is the course members' lack of preparation in basic science - physiology as well as pharmacology:

"I think it reflects that as part of their undergraduate teaching there is not a huge component to pharmacology within that, so they feel themselves that they are at a disadvantage". Pharmacology lecturer.

"They don't have a good physiology background in terms of when they come to the course, and you ask them about a cell and cell structures and that, some of them are very good and know what you are talking about, other ones don't". Pharmacology lecturer.

"Sometimes, when I am doing my teaching on the individual groups of drugs I have to spend time at the beginning going back and reviewing … system physiology, just physiology of the body - I have to remind them what is going on so that you can explain to them what the drug is actually doing". Pharmacology lecturer.

"We have to constantly readdress the basics in physiology". Pharmacology lecturer.

"The volume of work that we have to cover … they've got to really try and absorb … the pharmacology of a huge range of drugs in a fairly short space of time and while they probably are much more familiar with the drugs for the area they are working in … if they are working as a rheumatology specialist nurse and they've not worked with an asthma patient in years, their pharmacology knowledge there is going to be very limited". Pharmacology lecturer.

6.42 The other source of the difficulty was the large amount of ground to be covered in a short space of time.

Best practice in teaching pharmacology

6.43 Teaching pharmacology on the nurse prescribing course thus faces at least 2 challenges - accommodating specialists within a generic course, and dealing with the difficulty some course members experience in learning this subject. The evaluation revealed that many of the courses were developing educational approaches which were meeting these challenges successfully. This section will focus on some of the 'best practices' which have been developed or which were suggested to the research team. These deserve to be developed further and shared between universities.

Customising the generic part of the course to accommodate all nurse specialisms

6.44 Some pharmacology lecturers were customising the generic part of the pharmacology course by illustrating the general principles with examples from relevant nurse specialties. As 2 pharmacology lecturers explained:

"The first … teaching sessions, the pharmacokinetics, the pharmacodynamics are very generic, so they apply to all disciplines. But what I do is I tend to explain both concepts in terms of a variety of drugs. For example, maybe use central nervous system drugs like the antipsychotics or antibiotics which are more likely to be administered by a nurse in the community for example and I try to use that diversity to try to address everybody's background". Pharmacology lecturer.

"Comments we've had back from nurses is the drugs we use as examples they might not prescribe …. but I think if we identified the needs of their service and where it was going to go, then we could then work with that to say; OK you are going to work in a cardiovascular hypertension clinic therefore we will give you some examples based on those drugs or if was somebody working in mental health, we could give them mental health examples". Pharmacology lecturer.

6.45 There is also a move towards 'blended learning' in which classroom instruction is blended with web-based self-directed study, such as the prescribing case studies developed by NES. The latter provide rapid and flexible access to examples of the administration of individual drugs which can be used by course members to contextualise the general principles of pharmacology and observe how they apply in their own areas of practice.

Addressing course members' anxieties and difficulties in approaching pharmacology

6.46 Many of the lecturers had developed pedagogical techniques for addressing the course members' worries about learning pharmacology. This generally involved an interactive style of classroom teaching which drew on the course members' experience of administering medication:

"What is really important with the current students is that their existing practical experience really contributes towards their ability to take on the information within the course and put it in context much more easily…..". Pharmacology lecturer.

6.47 Lecturers commented that the course members often possessed a deeper knowledge of basic science than they acknowledged, and in consequence some lecturers began the pharmacology course by activating this dormant knowledge before providing new information:

"One of the things … I do … is to pool their reading learning and directed learning together and actually put it into the context of what they have seen in practice and to try and demonstrate that they actually do have an underpinning knowledge base already. And a lot of that is about confidence boosting and trying to put it into context for them". Pharmacology lecturer.

6.48 This kind of teaching is face-to-face, 2-way, sensitive to the course members' worries about the subject and adaptive to their current level of understanding:

"There is no set idea of what it is that they are going to get in this module when they see me. I start defining things from the beginning and they realise that they have done some biology and some chemistry before and this comes together in this area and we talk about pH and most people have done that at school, although a long time ago, but there you do get people bringing the memory back of pH relates to a level of acidity or alkalinity, this thing does relate to how a drug may be absorbed and metabolised in different areas of the body and it comes from there". Pharmacology lecturer.

6.49 Similarly, personalised support might also be delivered by distance learning, on-line in discussion sessions or through telephone conferences and tutorials.

Pre-Course Preparation

6.50 A small number of courses provided some form of pre-course preparation. This tended to focus on study skills and a typical approach was to use an existing university module designed for mature 'return to study' learners across all subjects. However, many of the pharmacology lecturers strongly supported the idea of developing a preparatory course to teach pharmacology prerequisites. This might comprise a combination of a pre-course reader and a self-administered test which could be used for diagnostic purposes. The view was expressed that these materials would need to be written specially for this purpose, as existing pharmacology textbooks were not tuned sufficiently closely to the specific needs of this course:

"I found that when they have had pre-reading before a session they are at a higher level and they're able to pick things up faster and question things in more depth. That [a pre-course study pack] would probably be beneficial although I don't know work wise that would fit in with their time commitments". Pharmacology lecturer.

6.51 Pre-course preparation would depend on improving the liaison between employers and course providers, as the latter often have very limited notice of which nurses would be attending the course.

Towards a curriculum model for nurse pharmacotherapeutics

6.52 Underlying the diversity of the courses, the research team identified an emerging model of a nurse prescribing curriculum. This was fully consistent with the official outline curriculum, but builds on it by engaging with the problems of its implementation. The 5 stage model is outlined here as a possible starting point for future curriculum development and evaluation.

The Curriculum model

6.53 Stage 1 . Preparation This stage focuses on prerequisite knowledge of physiology, basic pharmacology and academic study skills. It also involves negotiating with the course members and designated medical prescribing practitioners to establish a shared understanding of the nature, requirements and benefits of the generic nurse prescribing course, and how it will fit with the nurse's professional development. This requires a personalised approach to deal with the diversity in the course members' professional and educational backgrounds.

6.54 Stage 2. Introduction to pharmacology This builds on the course members' previous clinical experience and using personalised, interactive teaching to instil confidence. This stage provides guidance on study strategies, especially how to integrate the generic and specialised parts of the curriculum and how these relate to the assessments. It begins the process of developing skills for carrying out the evidence-based analysis of nurse prescribing practices needed for the portfolio, and ensures that course members are familiar with what the other assessment techniques will expect of them.

6.55 Stage 3. Generic model of prescribing

"… the skills and knowledge to be able to prescribe in general. So I think what we are giving them is a framework that they can then apply to their own practice rather than intensive study on clinical areas that they think they might need. So it's trying to give them skills that they can then apply to different situations and know how to apply them … how you prescribe an antibiotic is generally the same as how you prescribe a painkiller, there are different things you consider but you are still considering why you are giving them the drug, what's the most appropriate drug, you're still considering what dose you give and how often you give it and any information the patient might need. The choice is obviously different because you've to choose the right painkiller for the right type of pain and the right antibiotic for the right infection, but you can distil that down into one general process that they can then apply". Pharmacology lecturer.

6.56 Stage 4. A systematic study of a full range of drugs.

6.57 Stage 5. Self-directed study to develop a personal core formulary alongside a broad understanding of a wide range of drugs. This may run either after stage 4 or in parallel with stages 3 and 4,

"A core formulary is where an individual develops a list of drugs that they will use in their practice and there are certain things they need to know about each of those drugs. They need to know what the drug is, how the drug works, what the pharmacological effects of the drug are, what the likely adverse drug reactions might be for that drug, the interactions. Issues like that they explore in detail for each drug that they use. Then they practise the actual practical aspects of delivering drug information about that drug to a patient so that they can tie in theory with actual practice because they need to translate their technical knowledge into something different for the patient, so that the patient can understand that and we try to get them to think about that well before they actually deal with it in practice". Course leader.

6.58 Thus conceptualised, the core formulary would provide underpinning knowledge for the supervised learning in practice. It would not replace the broad study of a range of drugs that the generic model implies; rather, it would enable specialist needs to be met within that generic model.

Linking the nurse prescribing course with service needs

6.59 The third theme to emerge from the interviews centred on the relationship between the courses and service needs. Both the practice of nurse prescribing and the programmes of preparation were in early stages of development. Many course leaders felt that meeting service needs depended on further developments in nurse prescribing itself, as well as on closer links between employers and the course organisers in particular.

6.60 Action is needed at both Scottish Government and Trust level to achieve this. Three main issues were identified in the interviews:

• The need to tighten the links between the employers and the courses
• The need to develop and clarify the procedures and infrastructure for nurse prescribing
• The need to provide some form of post-course support for the newly qualified prescribers

The need to tighten the links between employers and courses

6.61 One problematic area is the admission of nurses to the courses. The standard pattern of recruitment is for a Trust to propose nurses for the course and for the university to then send them application forms. If an applicant is admitted, some pre-course preparation might be attempted. One university asks course members to undertake preparatory studies and uses these to diagnose needs for pre-course study skills training. The possibility of offering pre-course preparation in basic physiology and pharmacology was discussed above. However, because of the loose coupling between the courses and the Trusts, this cannot be implemented for everybody;

"We know what will happen is that, maybe three quarters of course members who have applied for and been offered places will come on the course, and then a quarter … will have fallen by the wayside. And unfortunately some of the course members do give their application form to someone else …. if that person hasn't got funding approved, they will just ditch it up. It is a situation that isn't very tight between the university and the Trust of getting this list of people named to actually commit to actually appearing on the day that the next course starts". Course leader.

"Lots of people think that once they have a place in September that it is alright to just say; oh I don't know I think maybe I'll just move to January". Course leader.

"The last application I had for the course that started in [date] was [2 days earlier]. So you get your cohort together very late? Very, very late. So it would be difficult to have a pre-course preparation? Yes and in fact one of my cohort didn't start until day 2. … people genuinely have difficulty deciding whether they're going to be able to accommodate the course until fairly short notice so you couldn't really offer much preparation … So there is preparation for those who are able to use it but obviously some people are coming to the course very late". Course leader.

The need to clarify nurse prescribing structures and procedures

6.62 Another issue was the difficulty of orientating the course to service needs because of the still-evolving structure of nurse prescribing in Scotland;

"One of the ... problems with directing courses is the ever moving goal posts of the …legal issues and the changes to the formularies on medical conditions. I think these are so difficult to determine …. I don't understand how a course member can understand where to … find out what they can and cannot prescribe … and there are Scottish legal differences in here that are not well flagged up … as far as directing courses, that for me is the biggest headache". Course leader.

"It would be nice if nurses in Scotland had some greater support in relation to the roles and requirements of nurse prescribers …". Course leader.

6.63 A consequence of this was that course members could not evidence all the competencies in the portfolio because the structure of nurse prescribing was still being put into place. Interviewees highlighted 3 areas that were problematic in this respect: working in teams, clinical governance and auditing.

6.64 Many course members were not working within multi-disciplinary teams, so they have difficulty demonstrating this aspect of their competence;

"The main competence which we have difficulty with is team work … when we talk about team work, we're actually talking about active communication between other members and making sure everybody in the team knows what you are doing … [course members] have difficulty articulating their actual place and demonstrating that they've linked to other members of the team actively to promote good prescribing practice". Course leader.

6.65 Similarly, systems for the clinical governance and auditing of nurse prescribing had not been established in all parts of the service, so in these respects too the course members' experience limited opportunities for developing practical competence;

"Clinical governance and audit work … sometimes they have difficulty showing that through their portfolio because … they're not linking into a structure that's already there". Course leader.

Need for post-qualification support

6.66 Course leaders perceived that, on completing the nurse prescribing course, members often lacked confidence and the leaders identified a need for post-qualification support to deal with this;

"I think it would be useful to have a structure for clinical supervision for prescribing aspects of your practice for new practitioners … specific nurse prescribing clinical supervision … there is a definite lack of confidence … there is no point in training people if they don't have the confidence to actually prescribe when they finish". Course leader.

6.67 It was pointed also out by some course leaders that currently, there is no funded CPD in Scotland to follow up the nurse prescribing course and this should be an area for future development.

The course members' perspective

6.68 Ten group meetings were conducted with course members, one group in each centre. The groups were held on the last day of each course (or as soon as possible thereafter). A total of 90 course members attended the 10 group meetings (47% of the cohort).

6.69 As described in Chapter 3 the nominal group technique was used for the group meetings with course members. This technique allows the group to share and discuss all the issues to be evaluated, with each group member participating equally in evaluation. The evaluation works with each participant "nominating" his or her priority issues, and then ranking them on a scale of, say, 1 to 10. The rankings allocated by each participant to each issue are added together to give a final ranking for that issue.

6.70 The categories for each group, which were broadly similar, were consolidated by the research team into 23 overall themes and the comments from all the groups were classified according to this schema. The number of importance-ratings allocated to each theme were then added together.

Findings

6.71 There were 11 positive and 12 negative themes (it should be remembered that the particular group method ensures this by eliciting a balance between positive and negative comments). Tables 6.9 and 6.10 list the themes in order of the importance-ratings they received. In the following sections, the 12 themes ranked of highest importance by the group participants are discussed together with opposing views where appropriate. When reading the following, the significance of each theme should be judged according to the overall importance-rating assigned by the course members.

Table 6.9 Summary of positive themes

Importance Rating	Theme
59 14	A. 15	The course contributed significantly to increased professional expertise and standing
55	B.	The course enabled course members to acquire important knowledge, mainly pharmacology
36	D.	The course enabled a beneficial networking with other nurses and professions, both at the university and in the workplace
20	H.	E-learning was helpful
16	K.	Interaction (peer support, group work and interactive teaching) was positive
16	L.	The teaching methods - lectures, assignments, handouts, workbooks, preparation for examinations - were effective
12	P.	The supervised learning in practice was beneficial
12	Q.	The course was well organised - accessible, relevant, flexible
10	S.	There was good tutorial support
7	U.	Study days were well-organised
3	W.	Remission of time from work to enable study was beneficial

Table 6.10 Summary of negative themes

Importance Rating	Theme
51	C.	Insufficient time
31	E.	Assessment procedures were a source of anxiety
28	F.	The course was poorly organised with regard to the scheduling of sessions, classroom facilities and course arrangements
27	G.	Certain aspects of the course did not contribute to the course members' professional expertise
18	I.	There was inadequate tutorial support
16	J.	The course was not sufficiently tuned to the needs of some specialities
14	M.	Study days at university needed to be better structured
13	N.	Problems were encountered in obtaining supervised clinical practice
13	O.	The pharmacology content was not appropriate
10	R.	Teaching methods were ineffective
8	T.	E-learning was ineffective
4	V.	The interactive aspects of the course were unsatisfactory

6.72 Theme A (positive). The course contributed significantly to increased professional expertise and standing.

6.73 The most strongly endorsed opinion in all 10 groups was that the course contributed significantly to increased professional expertise and standing, with an importance-rating of 59. On this basis, the main conclusion of the evaluation must be that overall, the courses were judged by the course members as fit for purpose. The benefits described in individual statements under this heading included:

• Greater professional confidence;
• Empowerment to provide better patient care;
• An expansion of their role as nurses; and
• Improved working relations with other professionals including GPs and pharmacists.

6.74 In the view of the course members these benefits arose from the comprehensiveness and relevance of the course, including its attention to the context and limitations of nurse prescribing, and the expertise it developed in working with the BNF, CMPs and the other resources available for prescribers. In the discussions, members commented that their "professional dignity" was "increased" and that they now had better relations with pharmacists and medical practitioners - "can talk about the pharmacology now".

6.75 Theme G (negative). However, there was a contrary view that certain components of the course did not contribute to the course members' professional expertise. This view was allocated an overall importance-rating of 27. In this category 15 of the importance-ratings were awarded because the course members thought that individual sessions were repetitive or not central to the work of a nurse prescriber e.g. consultation skills or the history of nurse prescribing; 7 reflected that there was a need for more emphasis on CMPs and practical experience with the BNF; 4 reflected the view that nurse prescribing did not enhance the course members' existing professional roles (e.g. one was already working with PGDs and saw no benefit from this course). The view that more employer support was needed if the benefits of training nurses in prescribing were to be realised was given an importance rating of 1. While stressing the importance of focussing on key issues, overall, this pattern of comments does not detract from the conclusion that the course significantly improved professional expertise.

6.76 Theme J (negative), - the course was not sufficiently tuned to the needs of some specialities. This view attracted 16 importance-ratings - not a major issue, but worthy of note. Two separate points were made within this theme: the course was sometimes perceived as aimed at community nurses rather than hospital nurses, and it was thought to be too generalised with not enough detail on the nurses' specialisms:

"a lot was relevant, a lot was not relevant, course needs to catch up with the applicants. A pool of different lecturers should be available to choose from or they could have a CD Rom with the lectures on".

"they wanted some opportunities to focus as a group on particular specialisms".

"it concentrated too heavily on primary care. The group agreed that a better balance was needed, as the class included several nurses from other specialties".

"The course needs to be tailored a bit for specialisms".

"Too generic pharmacology, needs more for specialists".

"The nurse prescribing course is not sufficiently relevant to ward nursing, it is too community based, the course must be more specific, course leaders should visit hospital based clinical areas to make sure that the course is more relevant".

6.77 The allocation of an importance-rating of 16 suggests that this perceived weakness in the course was not a major one overall. On the other hand, only 28% of the nurses who began the course described themselves as working in acute hospitals, and it is possible that an importance-rating of 16 underestimates the seriousness of this problem for that sub-group. The problem could be addressed by more widespread adoption of the methods for customising the courses, as described in the previous section.

6.78 Theme B (positive). In the view of course members the second most important aspect of the course was that it enabled them to acquire knowledge they valued. This attracted an importance-rating of 55. The knowledge referred to was chiefly a systematic understanding of pharmacology to underpin the course members' practice. This is related to Theme A, but it is listed separately because the groups frequently identified 'knowledge' as a separate theme. Pharmacology was the main constituent of this valued knowledge base with an importance-rating of 37. Course members also mentioned knowledge of legal, ethical and accountability issues, physiology, pathophysiology and anatomy each with an importance-rating of 1 and Information Technology with an importance-rating of 5. 'Knowledge' without further specification attracted an importance-rating of 12.

6.79 Typical statements under this theme included "excellent pharmacology education" and "We have learned basic principles of pharmacology and that is good". There was "more respect from pharmacists" - previously, some group participants said, nurses were "seen as semi-professional" but "now we are professional". In discussions, the groups stressed that the course had enabled them to understand the actions and interactions of the drugs they encountered in their practice. Many reported that the course stimulated critical thinking about medication, and that they valued the increased awareness of adverse drug reactions and contraindications that the course had given them - "it's worrying what you didn't know before". The comments "Now we can talk to doctors about drugs" and "Can join in the conversation" indicates the importance of this knowledge base for facilitating collaborative practice. Many of the course members also felt that they were able to give patients better explanations of the drugs they were taking.

6.80 Theme C (negative). The most strongly emphasised negative aspect of the course was that there was insufficient time. This attracted 50 importance-ratings. This might have reflected the overall duration of the course, but other factors were mentioned:

• Many group participants said that they were not given sufficient (or any) study time by their employer (see table 6.8 - as many as 27% of the course members had not been allocated any protected study time other than the university contact days, and if those who were still trying to negotiate study time when the course commenced are included, this figure rises to 45%).
• Even when protected time was allocated, there might not be backfill at work so their professional duties still claimed time that could otherwise have been devoted to study
• The course caused problems of maintaining work/study/home life balance, especially for those with young families
• There were problems fitting in the 72 hours' supervised learning in practice especially if the nurse worked part-time or nights
• If a course ran over the summer holiday period, this time could not be used as productively as the same amount of time at other parts of the year

6.81 Discussion in the groups elaborated on these points;

"The course should be longer for example, 7 months so that it is less concentrated. Management have to recognise the need for time, it is very uneven from nurse to nurse on the course, wide variations on how much time course members are allowed. Funding for protected time not being uniformly utilised".

"It was very stressful trying to work, especially when you have a family and with an exam, and they haven't done an exam for ages".

"This course ran over the summer holidays, but didn't take into account that the workplaces would have reduced staff and also people had children at home".

"The group felt that they needed more study time than the course organisers recommended to them. The course tutors were unsure about what was needed. Initially, they recommended 4 hours' private study per week, then amended this to 7-10 hours per week later.

Group members reported that the real requirement for study time was more than this. One member suggested that a whole day per week should be available for private study, which would need to be augmented by additional study on other days.

6.82 Theme D (positive). The fourth most important issue, judged by the group ratings, was that the course enabled a beneficial networking with other nurses and professions. This aspect attracted an importance-rating of 36. The networking occurred both with fellow course members on the university course and with other professions in the workplace (especially with GPs and pharmacists). Statements emphasised the value of this networking for patient care;

"meeting nurses from other areas of practice - now feel can contact them if problems with patients in their area of expertise".

"participation [in the course] encourages more interaction/co-operation with other health professionals".

6.83 In the discussions, course members expressed support for the generic nature of the course, because it enabled them to meet a lot of nurses with different professional backgrounds.

6.84 Theme E (negative). Assessment procedures attracted negative comment and were clearly a source of anxiety, with a relatively high importance-rating of 31. Whilst one would not expect course members to vote in favour of assessment, the comments did reveal some particular problems. The main one was the difficulty in understanding what was required for the portfolio, which for many course members was a novel exercise. The view was expressed that course members should be prepared for this more extensively - and earlier in the course. In fact, inspection of the course timetables shows that all the courses devoted a significant amount of class time to this, although the periods timetabled varied between 2 and 10_ hours. Clearly, courses offering lesser amounts of time for this need to consider whether it is sufficient. Another point was that some course members had not taken an unseen examination for many years and the examination caused them some stress. Again, some form of preparation would have been welcomed by many. Comments elaborating on this theme included;

"the emphasis was on the exam but this wasn't reflected in the sessions, we needed more prior knowledge about the exam"

"The portfolio method was insufficiently explained at the start of the course.

The group felt that they needed more examples of completed portfolios early on in the course and were concerned that they'd only been given one example.

6.85 The remaining themes in the group deliberations related to overall course organisation and specific teaching and learning methods, such as lectures, tutorial support and opportunities for interaction in the classroom. All these issues attracted both positive and negative comments, reflecting variations in arrangements across and within courses, and no doubt variations in the course members' expectations and preferences. Compared with the themes discussed above, which the groups considered the most important, these carried less weight. They are properly a matter for internal course evaluation, not policy making at national level. Nevertheless, for completeness, and to suggest issues for internal evaluation, they are discussed in the following pages.

6.86 Theme F (negative). The next most important issue (importance-rating of 28) was that (some of) the courses were judged to be poorly organised. Comments included a lack of clarity in the course programme, lack of communication between the course organisers and the course members (and sometimes among the course organisers themselves), a poor standard of teaching accommodation, lack of or late distribution of pre-course information and an illogical sequencing of sessions. However, in contrast some groups commented on how well their own particular courses were organised, emphasising in particular their flexibility and accessibility.

6.87 Theme H (positive). Many course members found e-learning helpful. This received an importance-rating of 20. In the small number of universities which made significant use of web-based learning, the Web CT platform was commended by course members as accessible, easy to follow on-line, well structured and with very good links.

6.88 Theme I (negative). Better tutor support was felt necessary, an opinion that attracted an importance-rating of 18. Comments focused on the lack of accessibility of tutors and limited feedback on work done.

6.89 Theme K (positive). Opportunities for interaction through peer support, group work and interactive modes of classroom teaching were commended. This was awarded an importance-rating of 16.

6.90 Theme L (positive). This was a compendium of praise for individual lectures, assignments, workbooks and library facilities, with combined importance-ratings totalling 16.

6.91 The remaining themes were judged of less importance overall by group participants and are not discussed here with the exception of Theme N (negative) which was also raised in the case studies. This theme was concerned with the problems in obtaining supervised clinical practice.

6.92 The concern was not the quality of the supervision but the lack of time the designated medical prescribing practitioners were able to devote to it;

"The Scottish Government must give time to mentors for mentoring, if this is very important you have to make sure that we have the support. We mentor student nurses - it is mandatory, but it is not mandatory for Doctors to do this".

"The mentors need protected time and a financial carrot"

6.93 Particular difficulties were reported in the Islands where face to face contact with visiting GPs may be limited and much of the communication was by telephone.

6.94 There was also variability in support from practices. One nurse who worked in 2 separate practices found totally different attitudes to nurse prescribing. One practice had a positive attitude to nurse prescribing while the GP at the other practice suggested the nurse prescriber knocked at his door to have prescriptions signed. There was a view that the system was not ready for nurse prescribers.

Summary and conclusions

6.95 The evaluation covered all 7 courses running in Scotland in the first half of 2005. Data were gathered from nearly all the 192 nurses enrolled, from all the course leaders and from the main lecturers in each course. Data sources included course documentation; an initial questionnaire to course members (participation rate 97%); interviews with course providers; and end-of-course focus groups in which 47% of the course members participated.

6.96 All 7 courses were implementing the NHS Education (Scotland) outline curriculum. However, there were minor differences in the emphasis placed on different objectives and also in the weighting of different elements of the assessment. All the courses blended on-site study days at the university with off-site private study. They differed in the relative weight assigned to these, some courses being predominantly campus-based and others predominantly distance learning. This met the requirements of a diverse user population. Interviews with course providers identified 2 main challenges: configuring the generic course to meet the needs of the range of specialties now taking it; and the task of teaching pharmacology to students with limited preparation for such study. Solutions to these problems were being implemented, but further curriculum development is needed to build on these advances.

6.97 The course-member focus groups had a strongly-felt conviction that the course contributed significantly to their professional expertise; that it provided essential knowledge of pharmacology and that it enabled a beneficial networking with other nurses and professions. The main difficulty, however, was insufficient time for study. Only 27% of the course members had been allocated any protected study time beyond the timetabled contact days at their university - which in the case of the distance learning courses were as few as 5 or 7 days for the entire 6 month course. Many other students were still trying to negotiate study time at the beginning of the course. Assessment procedures were another source of anxiety, and in some (but not all) centres students felt that the course was poorly organised with regard to the scheduling of sessions and the provision of classroom facilities.

Application of the Findings

6.98 Based on the findings, a number of recommendations have been made about the future development of the courses. These have been considered by the course leaders and by the Research Advisory Group in Scottish Government Health Department (formerly Scottish Executive Health Department) and as a result an extensive programme of course development was begun in 2006.

6.99 The study has described and evaluated different approaches to nurse prescribing training with regard to learning experiences and preparation for practice. This has been nested in the larger studies and was informed by our 2005 nurse prescribing questionnaire.

Implications of this work

6.100 There are difficulties which some course members experience in obtaining protected time for private study in addition to the time they are given for attending course contact days. If employers reviewed their policies for allocating such time and courses made their requirements explicit, especially where the course involves a low ratio of on-site to off-site study, this would be addressed.

6.101 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.

6.102 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.

6.103 There is a need for closer liaison 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.

6.104 Services need to ensure that nurse prescribing practices are underpinned by adequate clinical governance and the courses should refer to this.

6.105 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.

6.106 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.

6.107 Mentoring was largely viewed in a positive way. However, nurses sometimes found it extremely difficult to get any allocated time with designated mentors (Designated Medical Practitioner DMP). Mentors themselves highlighted 'finding time' problems and difficulties in understanding their role. One solution proposed related to nurse prescribers in training having 2 mentors: one clinical and one nurse prescriber who had experienced the course.

6.108 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.