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• To understand the benefits of nurse prescribing for patients, clinicians and healthcare systems
• To identify techniques that can improve the confidence of aspiring and novice nurse prescribers
• To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Nurse prescribing has been introduced in many countries with benefits for patients, prescribing clinicians and healthcare systems. However, nurse prescribing is not without challenges and the role of nurse prescriber has been debated. Some nurses may be reluctant to take on the role because they are concerned about making prescribing errors, acquiring sufficient knowledge and skills, or having to give up some of their other nursing roles. This article discusses the fundamental requirements for nurses to become effective and safe prescribers, a process underpinned by developing confidence, autonomy and collaboration – in particular with prescribing mentors. This article is written from the combined perspectives of the Australian and UK contexts.
Primary Health Care. doi: 10.7748/phc.2021.e1723
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondencerachael.summers@health.nsw.gov.au
Conflict of interestNone declared
Summers RE, East L (2021) Nurse prescribing: developing confidence, autonomy and collaboration. Primary Health Care. doi: 10.7748/phc.2021.e1723
Published online: 21 April 2021
This article aims to encourage nurses to consider becoming a nurse prescriber by explaining what it involves, notably in terms of developing confidence and autonomy, and collaborating with others. After reading this article and completing the time out activities you should be able to:
• Outline how the nursing role has changed in recent decades with the emergence of nurse prescribing.
• Describe how nurse prescribing is enabled and underpinned by professionalism, accountability, confidence and autonomy.
• Acknowledge the role of reflection, self-awareness, self-development and experiential learning in becoming a nurse prescriber.
• Discuss the importance of the role of mentors to support novice nurse prescribers.
• Identify resources that can assist aspiring and novice nurse prescribers.
• Non-medical prescribing aims to improve patients’ access to healthcare
• Nurses may be reluctant to become prescribers because they are concerned about making prescribing errors, acquiring sufficient knowledge and skills, or having to give up other roles
• Nurses may feel ambiguous about nurse prescribing, since the additional responsibility does not always come with acknowledgement or financial compensation
• Becoming a nurse prescriber involves developing confidence and autonomy through processes such as formal feedback or situational learning
• Some of the challenges of nurse prescribing can be overcome by long-term mentoring
Historically, prescribing medicines was the sole responsibility of doctors, but in recent decades non-medical prescribing has been introduced in many countries to improve patients’ access to healthcare. Non-medical prescribers include nurses but also pharmacists and certain allied health professionals.
Nurses have been administering medicines prescribed by others for many years, and with experience often find themselves having open discussions with prescribers as to which medicines or method of administration may be appropriate for a patient. However, the growth of the nursing role to encompass prescribing is relatively new, since nurse prescribing was gradually introduced in the UK from 1998 onwards (Royal College of Nursing 2014) and in Australia in 2010 (Dunn et al 2010). The introduction of nurse prescribing has supported patients to access treatments that might have been delayed in the past and has proved invaluable, for example in rural and remote areas where a shortage of doctors has affected access to healthcare (Harvey 2011).
Select one group of medicines that you commonly administer or possibly prescribe as well. In your view, how should nurses take account of the patient’s circumstances when administering and/or prescribing those medicines? For example, do nurses need to consider how a patient’s living conditions may influence their long-term use of analgesics?
With nurse prescribing, nurses are endorsed to prescribe certain medicines within parameters set by their professional standards and scope of practice, usually following a period of training and supervision. Nurses are well placed to prescribe, given that they already provide holistic care to patients, which means they can evaluate the patient as a whole and consider all the implications of prescribing a particular medicine. Prescribing involves using clinical judgement, which is contextualised to the patient’s circumstances and takes account of the appropriateness, safety, efficacy and judiciousness of medicines.
Nurse prescribing is not without risks. Prescribing errors can cause harm to patients as well as to the healthcare system, financially and in its reputation. This may cause a dilemma for nurses, who are expected to preserve patient safety (Nursing and Midwifery Board of Australia (NMBA) 2018, Nursing and Midwifery Council (NMC) 2018a).
Prescribing presents many challenges for nurses who want to become prescribers and for those who already are prescribers, such as advanced nurse practitioners in the UK and nurse practitioners in Australia, Canada and the US. These challenges include:
• Developing their role from administering medicines to confidently prescribing them.
• Securing acceptance of their prescribing role by others, including colleagues and patients.
• Maintaining an in-depth knowledge about medicines in a constantly changing pharmaceutical environment.
• Developing risk awareness and accepting accountability within their practice.
• Identifying who can support them in this advanced role.
• Developing their clinical judgement and understanding their limitations.
Prescribing, preparing and administering medicines are high-risk activities that can have negative health and economic consequences, including increased hospital admissions and patient death (Anderson and Abrahamson 2017). Elliott et al (2018) estimated that 66 million potentially clinically significant medication errors are made in England every year, approximately 34% of which are accounted for by prescribing in primary care. Although nurses may have an optimal level of pharmaceutical knowledge about medicines they frequently administer, the fear of making a prescribing error may deter some from becoming prescribers. This fear of making prescribing errors, alongside a lack of awareness of the existence of nurse prescribing and ambiguity towards the role of nurse prescriber, has hindered the development of this aspect of the nursing role (Devane and Leahy-Warren 2015).
The role of nurse prescriber has been the subject of debate, in the literature and among nurses. Some nurses may be reluctant to take on the added responsibility of prescribing because they perceive it to involve giving up traditional nursing work and exposing themselves to criticism.
Noriyo and Cashin (2018) suggested that nurses have experienced a medicalisation of their role because of a shortage of doctors and that many nurses may view this as a disincentive to becoming prescribers. Fong et al (2015) suggested that although the addition of prescribing to the nursing role may have originally been intended to provide patients – and nurses themselves – with a complete care experience, some nurses may be pressured to prescribe to the detriment of their other roles and may not be adequately compensated for the additional responsibility in terms of salary. Cresswell and Campbell (2019) noted an imbalance between the risks and rewards for nurses of taking on prescribing; for example, despite the additional responsibility – and potential additional anxiety – there is often no acknowledgement or financial compensation for prescribers.
Think about an occasion where you noticed that one of your colleagues had made a prescribing error, or maybe where you made a prescribing error yourself. Where did the error originate? For example, was it related to medicine selection or dosage? To route or frequency of administration? What was the root cause of the error?
Prescribing presents challenges for all prescribing clinicians. Rothwell et al (2012) suggested that all prescribing clinicians could benefit from quality improvement and experiential learning from each other’s mistakes. However, research has shown that nurse prescribing is as safe as – if not safer than – medical prescribing (Funnell et al 2014). Funnell et al (2014) suggested that the reason for this is that nurses tend to have better clinical judgement skills and are generally more risk averse than other healthcare professionals, particularly doctors. Black et al (2020) found in a study conducted in UK sexual health services that medication errors made by nurses predominantly comprised documentation omissions and that most of these omissions were ‘minor’, such as missing prescriber details.
Some nurses may not regard prescribing as part of their role, but research suggests that patients’ opinions of nurse prescribing are largely favourable, with many viewing it as an extension of the nursing role and one which supports efficiency and continuity, thereby contributing to an optimal use of resources (Courtenay et al 2011). Stenner et al (2010) suggested that prescribing has benefits for nurses (for example, higher levels of decision-making) and for patients (for example, being treated as partners in their care, in line with nurses’ person-centred approach), which in turn will reinforce patients’ positive opinions of nurse prescribing.
In one Scottish study, nurse prescribing was generally well received by members of the public, who recognised its convenience (Coull et al 2013). Nurse prescribing is equated with longer consultation times, which are generally viewed positively by members of the public (Bentley et al 2016), and extra time during consultations enables nurses to gather more patient details and reducing the risk of errors.
Ben Natan et al (2013) suggested that nurses are more respected by the public if they have the ability to prescribe than if they do not, as prescribers are perceived as hard-working and worthy of appreciation, and because safe prescribing practice is perceived as requiring a high level of education.
Hoti et al (2011) found that doctors viewed non-medical prescribing favourably, provided it occurred in partnership with a medical counterpart – as is the case in supplementary prescribing – since this reduced pressure on overloaded healthcare services, in turn reducing doctors’ workloads and the potential for errors. An increasing range of healthcare professionals are becoming independent prescribers and therefore have the autonomy to prescribe without medical supervision. Hindi et al (2019) said the one element of independent prescribing that patients appeared to value was teamwork and ongoing communication between the multidisciplinary team members involved in their care, including doctors.
Nurses’ professional code of practice is similar in the UK and Australia in stating that any treatment needed by patients must be delivered without undue delay and that nurses must maintain the knowledge and skills required to practise effectively and accountably (NMBA 2018, NMC 2018a). Nurses typically prescribe from a limited list of medicines, as defined by their scope of practice and within the boundaries of their specialty. However, prescribing has the potential to cause a dilemma for nurses who see it as a necessary extension of their role but lack the knowledge and confidence to undertake it.
In the UK, the Royal Pharmaceutical Society’s competency framework for all prescribers provides guidance and reassurance to prescribing clinicians, who may feel overwhelmed by the legalities and governance involved (Royal Pharmaceutical Society 2016). The framework provides a structure for prospective and current prescribers who want to improve their practice, reinforcing the principle that prescribing should be undertaken as part of a team, with knowledge and decision-making shared between all parties, including patients.
Imagine that you work in a general practice and have been asked to consider adopting a prescribing role, since this will not only improve patients’ access to services but also release GPs’ time. If you agree to train as a nurse prescriber, how do you envisage your working relationships with your medical colleagues, especially in the first few months of your new role? For example, would you expect them to be available to you for consultation and guidance? Would you expect to be completely autonomous?
Funk and Weaver (2018) supported the team element of prescribing and recommended that prescribers should not work alone. Establishing collegiate relationships with other healthcare professionals is recommended, not just from a safety perspective but for individual nurses to gain reassurance from colleagues and strengthen their decision-making. Beck (2020) suggested that preceptorship and mentorship programmes for nurse prescribers should be collegiate and promote working relationships in which nurses feel they can readily consult their preceptor or mentor.
Collaboration is invaluable in developing confidence as a nurse prescriber (Maylone et al 2011). One of the few concerns about nurse prescribing expressed by members of the public is the potential lack of collaboration between nurses and doctors (MacLure et al 2013). Collaborative models of care have been described in the surgical setting between nurse practitioners and physicians (Norful et al 2018), in general practice between nurses and GPs (McInnes et al 2017) and in the community setting between nurse practitioners, geriatricians and pharmacists (Reidt et al 2016).
For potential nurse prescribers, working in an unfamiliar collaborative model of care may involve additional exposure to uncomfortable and challenging situations, so it is reassuring to have access to a senior prescribing mentor. Initiatives such as the introduction of electronic prescribing, which incorporates built-in safeguards aimed at reducing prescribing error rates, can also provide reassurance to potential nurse prescribers (Roumeliotis et al 2019).
Williams et al (2018) observed that nurse prescribers in primary care out-of-hours services had longer consultations and were more pragmatic than GPs in the range of treatment options offered to patients, and that GPs and nurse prescribers readily communicated with each other about their prescribing practices, thus developing awareness of their respective limitations and identifying opportunities for supervision. Lim et al (2018) supported a process of collaboration, stating that prescribing is primarily concerned with developing confidence through receiving feedback about one’s practice of core skills and knowledge of medicines.
Although confidence levels can be regarded as personal and subjective, research into developing confidence to prescribe suggested that providing an organisational structure that values learning promotes positive attitudes towards prescribing (Weglicki et al 2015). Without supportive learning strategies, confidence may be high but competence may still be low (Brinkman et al 2015).
Weglicki et al (2015) advised that anxiety caused by a fear of prescribing can be alleviated by structured learning processes developed collaboratively by employers and higher education institutions. Lönnbro et al (2019) proposed that prescribing can be viewed as an ‘art’ that has to be learned by completing specific educational processes, while Knopf (2019) said the training of novice prescribers mentored by a seasoned clinician was similar to the training of apprentices learning their trade under the guidance of an experienced colleague. In medical training, shadowing a more experienced colleague has been found to assist new medical prescribers by reducing their fear of making errors and giving them time to ask questions and discuss issues (Cheetham et al 2020).
Identify actions that you could take to develop your confidence and autonomy in becoming a nurse prescriber. For example, you could listen to podcasts on the NPS MedicineWise website, available free of charge at: www.nps.org.au/podcast Consider setting yourself diary reminders to complete one new action every week.
Much of the literature – for example, Kusurkar and Croiset (2015) – suggests that developing autonomy involves a process of personal development and individual experiences, which contribute to a unique personal trajectory. The process of developing autonomy is challenging to quantify, because it is largely the by-product of the individual’s circumstances and the people they are surrounded and influenced by.
Developing autonomy is primarily an experiential process of becoming organised, communicating with others, establishing expectations and integrating knowledge (Weston 2010). Athey et al (2016) explain that for nurses, developing autonomy can be interpreted as attempting to reach a point where they are comfortable with their level of skills, where their role is clearly defined and where their clinical knowledge has reached a high level. At that point, job satisfaction increases and autonomy stabilises.
The development of an individual’s autonomy to prescribe is mainly enabled by self-empowerment and self-reliance, but also involves forming relationships with others who can support the novice prescriber (Weiland 2015). Although education and knowledge are the basis of many autonomous decisions, it is confidence and experience developed over time that support the process of seeking informed consent from patients, particularly where prescribing is concerned (Skår 2010).
Formal feedback and audit can assist in developing and maintaining the prescriber’s autonomy, since they enable the prescriber to correct any suboptimal habits that may have developed, leading to reduced errors and improved prescribing skills (Cappanera et al 2019). Situational learning can assist by confronting the novice prescriber with challenges – such as difficult diagnostic or treatment decisions – within the safety and comfort of a mentoring relationship where decision-making can be freely discussed and fine-tuned (MacMillan et al 2016). Walls (2019) argued that for prescribers, situational learning is transformative and invaluable in the process of lifelong education and self-development.
The early selection of mentors who not only support novice prescribers but challenge them to think beyond a diagnosis or a medicine can be crucial to the development of autonomy. RES (first author) chose three mentors who would each bring different elements, professional perspectives and personal qualities: an experienced nurse practitioner, a GP and a pharmacist.
It can be challenging to maintain up-to-date knowledge about medicines in a constantly changing pharmaceutical environment, but this challenge can be overcome through long-term mentoring relationships with senior clinicians (Harrington 2011). Research has shown that collaboration between nurse prescribers and pharmacists can benefit all parties, including patients, through the provision of ongoing education focused on the appropriate use of medicines (Fletcher et al 2012), and can aid a reduction in prescribing and dispensing errors (Cleary-Holdforth and Leufer 2013). Learning about medicines can be daunting, so working with healthcare professionals such as pharmacists can be invaluable (Woo and Robinson 2015).
Agencies that provide information on medicines including NPS MedicineWise (formerly known as the National Prescribing Service or NPS) in Australia and the NHS Specialist Pharmacy Service in the UK make it clear that prescribing requires consistency and standardised processes followed by all clinicians who have prescribing rights. Online medicine resources include the British National Formulary publications, MIMS Online) and MedicinesComplete.
One of the prerequisites for acceptance on a nurse prescribing training programme is a specific amount of post-registration experience. The time frame varies between countries. In the UK, nurses can undertake the independent/supplementary prescribing training programme after a minimum of one year of registered professional practice (NMC 2018b).
In Australia, a registered nurse must have at least three years of full-time experience working at an advanced level before enrolling on a nurse practitioner master’s degree course (Australian College of Nurse Practitioners 2021). Other requirements to become a nurse prescriber include mentoring by a prescribing clinician such as a doctor (Cope et al 2016). These prerequisites ensure that nurses already have a predetermined level of knowledge and skills in the area in which they intend to prescribe.
Nurse prescribing training programmes may focus on inappropriate medicine use (Weddle et al 2017), on developing analytical skills, and on the responsibilities and tasks involved in prescribing (Rogers 2010). Funnell et al (2014) argued that once the practicalities of prescribing have been covered, all that nurse prescribers require is confidence and self-belief, which can only be gained under the guidance of a mentor. Copeland (2012) suggested that the selection of mentors needs to be carefully considered, since prescribing clinicians with more education do not necessarily make more effective mentors. Smith et al (2019) suggested that the selection of mentors is of utmost importance, since if micromanagement and over-scrutiny occur, nurses will not only lose confidence but also become isolated in their practice.
Although having skilled mentors who are able to increase their mentees’ confidence and self-esteem is important, a commitment to ‘doing it right’ is also required. That commitment is probably more important than knowing every detail of all of the medicines the nurse is allowed to prescribe - and attempting to reach such a level of knowledge may feel insurmountable and be self-defeating. With a commitment to prescribe appropriately and correctly, learning can be ongoing, occurring as various situations arise in collaboration with mentors.
Nurses need to understand and question the context in which they are potentially extending their role to include prescribing. For example, it is important to consider whether the added role will use their skills and work, whether it will enrich their professional relationships with others, and whether they will be offered the resources to undertake the role effectively. Nurses need to feel comfortable with their professional prospects if they decide to become prescribers.
The relatively recent introduction of nurse prescribing has not only supported patients’ access to healthcare but also lessened the workload of medical prescribers and provided nurses with opportunities to develop their skills and progress in their careers. However, some nurses may be reluctant to take on prescribing because of fears about medication errors, concerns about giving up traditional nursing activities, and anxiety about attaining the levels of knowledge and skills required. While confidence, autonomy and collaboration with others are essential components in the process of developing safe prescribing practice, nurses who aspire to become prescribers will also need to draw on crucial resources such as the support of carefully selected prescribing mentors and optimal working relationships with medical colleagues.
Consider how developing confidence and autonomy in prescribing relates to The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018a) or, for non-UK readers, the requirements of your regulatory body.
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account
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