Analysis of the about Nurse Prescribing - Literature review Example

 Literature Review on Nurse Prescribing Introduction In 1998, Nurse Prescribing was nationally introduced resulting from the first Crown Report of 1989 and the Cumberlege Report of 1986 both by the Department of Health. The Medicinal Products: Prescription by Nurses etc Act of 1992 served as the legal framework that gave way to nurses prescribing under a limited formulary called the Nurse Prescriber’s Formulary or NPF (Freeman). The initial course included health visitors and district nurses, but did not include practice nurses except if they had a district nursing or health visiting qualification. The basic rationale given as to why the inclusion of nurses was limited to health visitors and district nurses was that they could be identified from the Unitd Kingdom Central Council for Nursing, Midwifery, and Health Visiting (UKCC) registry if they have completed further education from the time of registration (Jones 10). As of 2002, nurse prescribers number to approximately 22000 in the UK, and of this number, 300 are in Scotland (Bates 63). The main goal of nurse prescribing is to give the utmost benefit to the patients. It aims to provide more efficient and faster access to health care. The duties of nurses in relation to prescribing after undergoing training include prescribing pharmacy and general sales list medicines which are prescribed by General Practitioners, and prescribing prescription-only medicines or POMs associated with certain medical conditions. The role of the nurses in making prescribing decisions has responsibility tagged with it along with accountability. The nurses are both professionally and legally accountable wherein they have to be thoroughly knowledgeable on the products or medicines they are prescribing, when these over-the-counter products should be recommended, and when certain products should not be prescribed or recommended. The nurse’s working knowledge should be based on the circumstances of the patients including the current medications, current health status, past health or medical history, ample information and understanding of the products’ dosage, therapeutic action, interaction, and side effects, data on the alternatives to prescribing, and the frequency of use depending on the conditions (Courtenay and Butler 5). While prescribing entails more responsibility, competence and more learning aptitude for the nurses, and exposes them to more possible liabilities and patient complaints, not all medical professionals are open to the perceived benefits of nurse prescribing to the patients, doctors and the nurses themselves. Looking at the bigger picture shows prescribing processes made easier by the ability and right of certain nurses to prescribe. It smoothens the process by lessening the dependency on doctors and their complicated schedules for prescribing. It eases the gap between the patients and the medical professionals by having dependable and reachable nurses for addressing issues or needs relating too prescriptions. This paper will present a literature review on three themes: The Current Issues, Perceptions, and Status of Nurse Prescribing, The Advantages and Disadvantages of Nurse Prescribing, and Efforts and Programs to Assure the Optimum Efficiency in Nurse Prescribing. It will likewise present recommendations for changes in practice, education and future research for nurse prescribing. I. Review of Literature A. The Current Issues, Perceptions, and Status of Nurse Prescribing Nurse Prescribing though promises better provision of health care was also met with skepticism as to its true aims. Nurse prescribing is perceived as both a means to improve the professional position of nurses by doing tasks previously done by the doctors, and a means to de-regulate medicines which paves the way for greater access to medicines and increase in choices available. The truth behind these perceptions has however been doubted by some sectors claiming that the true aims of nurse prescribing are: to transfer of routine medical duties to nursing, to save money, and to challenge the foundation of professional medicine (McCartney, Tyrer and Brazier 348-354). A study of the background data of nurse prescribers and their perceptions of their roles as nurse prescribers was undertaken by Bradley, Campbell and Nolan (439-448) to provide more information on their demographics, educational needs and expectations. The respondents of the survey were nurses who took a course on nurse prescribing at a West Midland University in 2003-2004. The nurses believed that prescribing would improve service delivery to the service users, advance the nurses’ professional development, and result to a better communication between patients and professionals. Majority of the respondents claimed to be already involved in ‘by proxy’ prescribing and considered the course as a formalization of what they were presently doing. The nurses expressed concerns regarding the degree of support the health care climate could provide due to the many other existing innovations. According to Latter and Courtenay (26-32) who made a literature review of the effectiveness of nurse prescribing, patients were generally satisfied with the prescribing of health visitors and district nurses in the initial phase of prescribing which spanned the years 1993-2002. The nurses were likewise satisfied with their roles in prescribing, but some felt that their pharmacological knowledge was inadequate. The literature review concluded that the evaluation of nurse prescribing had been positive so far, but there are procedural weaknesses and lack of research data on certain important issues While and Biggs (559-567) conducted a mail survey of all district nurses and health visitors working in southern England from three primary care trusts to determine the benefits of nurse prescribing and the challenges they face. Of the total number of target nurses, 74% responded and results showed that the nurses did not act as substitute prescribers to general practitioners. The responses showed that the effectiveness of nurse prescribing depends on certain conditions such as the sufficient preparation and education of nurses, acceptance of the role by the practitioners themselves, and a formulary which addresses the needs of the practitioners. Data on the expectations of mental health and non-mental health nurses regarding their roles as nurse prescribers were gathered and analyzed by Nolan and Bradley (258-266) through a questionnaire-based study. The perception of non-mental health nurses revolved around the premise that prescribing would result to better efficiency and a maximization of resources, while the mental health nurses perceived prescribing as a benefit to clients resulting to enhanced access to care, improved quality of care, increased choice, and more information about treatments. A research involving qualitative interviews was undertaken by Fisher (102-107) to determine the impact of nurse prescribing to the relationships between prescribers, doctors, nurses, pharmacists, carers, and patients. The findings showed that independence of the prescribing workforce have not been achieved and some prescribers are even slipping back to their behaviors before they began prescribing. Courtenay, Carey and Burke (698-707) made a study in 2005 to determine the extent to which independent extended supplementary nurse prescibers feel prepared in prescribing medicines. Their respondents were nurse prescribers of patients with dermatological conditions. Their findings revealed that the roles of nurses in the management of skin disease were extended due to prescribing. In order to be effective in prescribing, these nurses need specialist dermatology training.   The professional issues involved and the status of nurse prescribing in low-resource settings was looked into by Miles, Seitio and McGilvray (290-296) to highlight the importance of the roles played by nurses in health care delivery in areas where there medical personnel are lacking. The study revealed that there is a need for a clear definition of the nurses’ role in ordering of medicines, the scope of their responsibilities, and their training needs. There is also a need for all health service levels to recognize the extended role of nurses, and a need for assessment of policies and outcomes relating to nurse prescribing. One aspect relating to the perceptions on nurse prescribing is the differences in the patterns of prescribing between the nurse practitioner and the physician. A study in a primary care setting for bronchitis, sinusitis, back pain, and musculoskeletal injury treatments was conducted by Running, Kipp and Mercer (228-233) to compare these differences. The findings showed that there was a significant difference in prescriptive patterns for only one instance. Slight differences were also observed in medication administration to patients. Nurse practitioners were more cautious in prescribing medications and they provided more information to the patients. B. The Advantages and Disadvantages of Nurse Prescribing A qualitative study on the prescribing experiences of nurses was conducted by Lewis-Evans and Jester (796-805) through analysis of interviews. Seven nurse prescribers who were prescribing within a community trust in the West Midlands were interviewed. The primary goal of the study is to provide information and understanding of the nurse prescribers’ experiences for reference and application to future practice. The analysis showed that the nurses perceive the duty of prescribing as a generally positive experience which offers advantages such as the increase in convenience of the patient, time saving for both patient and nurse, and increase in the autonomy and role satisfaction of nurses. Negative experiences were centered on the restrictions on the prescriber’s practice due to the limitations of the nurse prescribers’ formulary and documentation duplication. Similarly, Bradley and Nolan (120-128) conducted interviews in the period 2005-2006 as basis of analysis for their study on the impact of nurse prescribing. Forty-five nurse prescribers who had qualified and had registered were interviewed. From the interviews, perceived advantages of prescribing included overcoming healthcare system difficulties like the delays in the access of patients to medicines, increase in work autonomy and job satisfaction, enhancement of knowledge of nurses on medications, and improvement of their confidence in making decisions relating to prescriptions. The study by Luker, Austin and Hogg (235-242) dealt with the benefits of nurse prescribing to the patients, difficulties that were experienced, and the views of patients about the role of nurses as prescribers. Interview was the method used. Results revealed that the main benefit patients felt was the accessibility and approachability of nurses as compared to general practitioners. Another study made to determine the perception on the advantages and disadvantages of nurse prescribing was done by Nolan, Haque and Badger (527-534) with focus on mental health nurses. Questionnaires were administered to 73 mental health clinical nurses in the UK with 14 of them working in in-patient settings and 59 in community settings. Majority of the nurses felt that nurse prescribing will improve the patients’ compliance, improve the access to medication, increase cost effectiveness, and prevent patient relapse. Many were worried though that they did not possess adequate skills and knowledge to do prescribing. The findings showed that to achieve the maximum benefits of nurse prescribing, further training should be provided along with thorough supervision, and the co-operation of doctors should be evident. C. Efforts and Programs to Assure the Optimum Efficiency in Nurse Prescribing In order to plan programs for developing or achieving efficiency in nurse prescribing, studies had to be made for assessing and analyzing the problems or barriers to the implementation of nurse prescribing. Hall, Cantrill and Noyce (403-412) made a study to determine the barriers that are preventing trained community nurse prescribers from prescribing. The method of the study used was a combination of interviews with nurse prescribers and the prescribing leads of the Trust, and questionnaires sent by mail. The barriers identified included roles of nurses with no patient contact, non-issuance of prescription pads, lack of confidence on the part of the nurse prescribers, opposition from the general practitioners, lack of time, security concerns, lack of access to the medical records of patients and use of substitute supply methods. Because of these barriers, the expected benefits of nurse prescribing may not be realized and efforts such as institutional support, development of strategies to afford nurse prescribers the access to medical notes of patients, and improvement of prescribing procedures are needed. Effective education programs may also be achieved through evaluating the existing or available education courses for nurse prescribers. A study made by Banning (435-444) provided information as to the insights, learning attitudes of students, perceived theory roles, and previous experiences of students. The study found that the students were generally aiming to learn and be successful but many are concerned about the required diagnostic skills and pharmacological content to make a clinical diagnosis. Giving students physical examination and normal physiology skills, pre-course readings, and guided studies in pharmacology would make them better independent nurse prescribers. Theoretical assessment tools would also give students the chance to review and evaluate their suitability for the program. A research was undertaken by Pontin and Jones (540-548) to ultimately provide data in developing effective training strategies. Their study was conducted among children’s nurses. Focus groups were asked questions regarding training, record keeping, supervision and development of confidence, autonomous practice, benefits of nurse prescribing, and the formulary. Results revealed that children’s nurses often give advice on prescribing issues to their junior medical colleagues, the focus of the content of courses should be on children, and one useful prescribing alternative is the patient group directives. Conclusion was made that the target of initial training should be the senior nurses or the specialist nurses to set a mass organizational culture change in motion. Another study was made to determine the training needs in nurse prescribing, this time conducted among family planning nurses. Tyler and Hicks (644-653) made a study on the nurse prescriber’s occupational profile and associated training needs. A valid and reliable training needs analysis instrument was sent out to family planning nurses. The results showed that the role of nurse prescribing was mainly defined in terms of its functions and that research was not considered to be important. Key points also included communication, administration, teamwork, and advance professional issues. The responses also laid out the top training needs of the nurses which could help in developing curriculum for educational programs. In order to address prescribing errors resulting from inadequate paper prescription forms, Kennedy and Benjamin (480-487) designed and evaluated a modified prescription form with the aim of reducing outpatient prescribing mistakes. Eleven health care providers comprised of nine physicians and two nurse practitioners took part in the before-after trial. The modified forms included prompts for medication form, name, dose, route, strength, quantity, refills, indication, frequency and additional directions. The trials revealed that the use of the modified forms reduced prescribing problems significantly as compared to the standard forms. II. Recommendations for Changes in Practice, Education and Future Research The practice of nurse prescribing will not be successful in achieving its aims without the support of the entire medical community. Although the benefits it provides to the patients or the service users will be enough to sustain its practicality and usefulness, the active support of other health practitioners will make the job of nurse prescribing easier and more efficient. Programs should be put in place in every possible venue for nurse prescribing to help nurses gain confidence and familiarity with the role or the duty. Procedures across the medical system should be streamlined and integrate to allow nurse prescribing to be practiced efficiently. Support from other medical personnel and adequate guidelines should lessen errors in nurse prescribing. The move of the government to increase nurse prescribing powers of nurses and pharmacists are opposed by doctors due to certain implications of prescription and administration of powerful or dangerous drugs. Prescribing of nurses was previously limited to drugs for palliative care and minor injuries, but this move will allow nurses to prescribe controlled medications usually prescribed by general practitioners for more serious health conditions like diabetes and heart disease (Meehan 3). The increase in the prescribing power of nurses entails additional and higher level of education and training that the nurses need to undergo. Educational programs and their curriculums should be based on training needs analysis or empirical research data to provide more relevant and effective learning experiences and outcomes. Continuous education and training should be undertaken periodically by nurse prescribers to refresh their knowledge and skills, and keep them updated with the developments in prescribing medications. Future research could deal with the viability or feasibility of legalizing nurse prescribing in other countries. Factors to be considered should include the availability of training programs and facilities in those areas or countries to prepare nurses for prescribing, the health care system climate, the legal consequences or accountabilities, the openness and acceptance of the majority of the population to such a measure, and the willingness and aptitude of the nurse practitioners to extend their role to prescribing. Regular research should likewise be carried out to monitor the status of nurse prescribing and its developments. This will provide data for improvement efforts relating to policies, strategies and organizational structures. III. Conclusion Nurse prescribing has demanded a great deal of effort, time and responsibility for the nurses. It has also presented difficulties and challenges to them. Although this is the case, nurses have been positive in accepting this extended role. The perceived and experienced advantages outweigh the disadvantages of nurse prescribing. Nurses, after all have imbibed the true meaning of their jobs as nurses, which is to be of service to those needing health care. The nurses believe that the main goal of nurse prescribing more than anything else is to increase the efficiency of service to the service users. It increases the users’ access to medication and thus improves their quality of life. Overall, nurse prescribing has improved the professional status of nurses, has increased knowledge and skill acquisition in the medical field, has developed better organizational structures, has improved medical system procedures, and more importantly has improved the quality of service given to the patients or the health care service users. Aside from the adequate and thorough education and training of future nurse prescribers, continuous training should be provided to existing nurse prescribers to sustain their competence and keep them updated with developments in medication prescribing. Support and cooperation among all the sectors in the medical profession or field are needed in order to achieve the goals of nurse prescribing. Works Cited Banning, Maggi. "Questioning Student Learning: an exploration of student's views on learning to become independent nurse prescribers." Journal of Further and Higher Education, Volume 28, Number 4 (2004): 435-444. Bates, Carol. "Independent nurse prescribing ." RCM Midwives Journal, Volume 5, Number 2 (2002): 63. Bradley, Eleanor and Peter Nolan. "Impact of nurse prescribing: a qualitative study ." Journal of Advanced Nursing, Volume 59, Number 2 (2007): 120-128. Bradley, Eleanor, Pam Campbell and Peter Nolan. "Nurse prescribers: who are they and how do they perceive their role? ." Journal of Advanced Nursing, Volume 51, Number 5 (2005): 439-448. Courtenay, Molly and Michele Butler. Nurse Prescribing Principles and Practice. London: Greenwich Medical Media , 1999. 5. Courtenay, Molly, Nicola Carey and Joanna Burke. "Preparing nurses to prescribe medicines for patients with dermatological conditions ." Journal of Advanced Nursing, Volume 55, Number 6 (2006): 698-707. Fisher, Rick. "Relationships in nurse prescribing in district nursing practice in England: A preliminary investigation." Internationl Journal of Nursing Practice, Volume 11, Number 3 (2005): 102-107. Freeman, Gill. "Nurse prescribing: the pros and cons. Diabetes and Primary Care." Summer 2006. FindArticles.com. 7 Nov 2007 . Hall, Jason, Judith Cantrill and Peter Noyce. "Why don't trained community nurse prescribers prescribe? ." Journal of Clinical Nursing, Volume 15, Number 4 (2006): 403-412. Jones, Mark. Ed. Nursing Prescribing: Politics to Practice. London: Bailliere Tindall, 1999. 10. Kennedy, Amanda G. and Littenberg Benjamin. "A Modified Outpatient Prescription Form to Reduce Prescription Errors." Joint Commission Journal on Quality and Patient Safety, Volume 30, Number 9 (2004): 480-487. Latter, S. and M. Courtenay. "Effectiveness of nurse prescribing: a review of the literature." Journal of Clinical Nursing, Volume 13, Number 1 (2004): 26-32. Lewis-Evans, Amanda and Rebecca Jester. "Nurse prescribers’ experiences of prescribing ." Journal of Clinical Nursing, Volume 13, Number 7 (2004): 796-805. Luker, K.A., et al. "Nurse-patient relationships: the context of nurse prescribing ." Journal of Advanced Nursing, Volume 28, Number (1998): 235-242. McCartney, W., et al. "Nurse prescribing: radicalism or tokenism? ." Journal of Advanced Nursing, Volume 29, Number 2 (1999): 348-354. Meehan, Fiona. "Nurse prescribing plans opposed." Journal of Community Nursing, Volume 19, Issue 12 (2005): 3. Miles, K., O. Seitio and M. McGilvray. "Nurse prescribing in low-resource settings: professional considerations." International Nursing Review, Volume 53, Number 4 (2006): 290-296. Nolan, P. and E. Bradley. "The role of the nurse prescriber: the views of mental health and non- mental health nurses." Journal of Psychiatric & Mental Health Nursing, Volume 14, Number 3 (2007): 258-266. Nolan, P., et al. " Mental health nurses’ perceptions of nurse prescribing." Journal of Advanced Nursing, Volume 36, Number 4 (2001): 527-534. Pontin, David and Susan Jones. "Children's nurses and nurse prescribing: a case study identifying issues for developing training programmes in the UK ." Journal of Clinical Nursing, Volume 16, Number 3 (2007): 540-548. Running, Alice, Catherine Kipp and Victoria Mercer. "Prescriptive patterns of nurse practitioners and physicians." Journal of the American Academy of Nurse Practitioners, Volume 18, Number 5 (2006): 228-233. Tyler, C. and C. Hicks. "The occupational profile and associated training needs of the nurse prescriber: an empirical study of family planning nurses ." Journal of Advanced Nursing, Volume 35, Number 5 (2001): 644-653. While, A.E. and K.S.M. Biggs. "Benefits and Challenges of Nurse Prescribing." Journal of Advanced Nursing, Volume 45, Number 6 (2004): 559-567. Read More