CHAPTER TWO : RESEARCH ON NURSE PRESCRIBING
2.1 This chapter outlines the literature which was used to underpin the development of the approach taken to evaluating the extension of independent nurse prescribing in Scotland.
2.2 The nurse prescribing literature has burgeoned since 2000. This body of literature was highlighted by a literature review published by the Scottish Executive in 2004 (Harris et al, 2004). Pollock (2006) undertook a further literature review looking at the costs of nurse prescribing, its effectiveness, and aspects of implementation that needed to be addressed to implement nurse prescribing safely. This study did not seek to duplicate past work, nor did it survey the totality of the nurse prescribing literature. Instead its focus was on the literature which was relevant to the project objectives and any additional research that was relevant specifically to nurse prescribing in Scotland. It did this by drawing on past reviews, searching the major electronic data bases including those covering medical and nursing journals such as Medline, CINAHL and other databases and search facilities available within NHS's electronic library. Much of the recent research literature focuses on views of nurse prescribers, patients and various professional groups on the 'benefits and challenges' of nurse prescribing. For example, Lewis-Evans and Jester (2004) conducted qualitative interviews with health visitors and district nurses and identified a series of themes around nurse prescribing 'benefits of nurse prescribing, support and role satisfaction, prescribing difficulties and patient-centred care'.
Research on nurse prescribers
2.3 There has been one large evaluation of nurse prescribing in England. This was conducted by Courtenay et al (2006) and used a 2 phase evaluation beginning with a national survey of independent nurse prescribers followed by qualitative work with nurses. As this work was carried out in 2004, it did not explore the further opening up of the BNF. Observation and post-consultation questionnaires were used with patients to explore their experience of nurse prescribing. Courtenay et al found benefits in patient care, increased professional autonomy; problems with prescription pad delays, and lack of computerised prescriptions. They found that nurse prescribers' main support was informal peer support. Patients were generally positive and had no major preference for doctor or nurse, although patients preferred to see doctors for certain conditions. The main reasons that patients gave for wanting nurse prescribing were: convenience, saving the doctor's time and a preference for a nurse in certain cases where patients found it "less embarrassing" to talk to nurses rather than doctors about their illnesses.
2.4 Most other research has focused on primary care and on health visitors and district nurses in particular. For example, in a postal survey of health visitors and district nurses in southern England conducted by While and Biggs (2004), district nurses were prescribing significantly more than health visitors and both groups reported increased prescribing confidence, improvements to their role and supportive information sources. Recent available statistics show that in some areas nurse prescribing in acute settings matches the level of activity in primary care. For example, Bradley et al (2005) found that there were almost as many nurse prescribers working in hospital settings as in general practice and community settings (40% and 54% respectively).
2.5 Small qualitative investigations using interviews and focus groups have mainly focused on general professional issues have also been undertaken (Travers 2005). These have included issues specific to nursing groups such as health visitors (Davies 2005), supplementary prescribers (Hay 2004), nurse prescribing effects on inter-relations between professionals patients and carers (Fisher 2005) and nurse-patient relationships (Luker et al 1998b) linked to patent views on convenience and continuity of care. This latter study also suggested that nurse prescribing added value and was well received by patients.
2.6 In addition, Banning (2004) explored the research literature on nurse education and various issues in nurse prescribing, including pharmacology knowledge, patient perspectives, treating minor injuries, clinical competence and professional autonomy. Latter and Courtenay (2004) identified key findings about the impact and effectiveness of nurse prescribing concluding that nurse prescribing has generally been evaluated positively to date. Methodological limitations and under-researched areas were also identified, including lack of research on cost effectiveness and the range of settings that nurse prescribers now work in. In addition, Latter and Courtenay (2003) suggested that further research on nurse-patient interactions would be beneficial.
Research on patient views
2.7 Few studies have focused on patient perceptions of nurse prescribing. Those which have included patients have focused on those who have been exposed to nurse prescribing, or on high, low and new users of nursing services (Luker et al 1998b; Brooks 2001). Berry et al (2006) sought the views of people who have not yet experienced nurse prescribing in order to determine their level of confidence in nurse as opposed to doctor prescribing. Most of the data on patients have been collected either within primary care settings - for example in community nursing settings (Luker et al 1998b) and in health visitor contexts (Brooks et al 2001) - or in the general population. In addition, studies have been limited to the use of the nurse prescribing formulary. More research is therefore needed on patient views since the legislative changes with the BNF and with patients within acute settings.
2.8 Patient perspectives of nurse prescribing have been generally positive, with participants in the Brooks et al (2001) study accepting nurse prescribing as a practical and responsive method of service delivery. More specifically, patients identified that nurse prescribers had key skills in assessment, observation, diagnosing and providing information. The benefits were seen in terms of better use of time, convenience and a quality relationship with the nurse. Disadvantages included the limitations of the nurse prescribers formulary at the time of the study and concerns around the training and competence of nurse prescribers.
Scottish nurse prescribing literature
2.9 Mullally et al (2003) provided a UK picture of nurse prescribing and nurse prescribing education that acknowledged which nurse prescribing in Scotland was seen as a "positive step". "Our National Health: A Plan for Action, a Plan for Change" ( SEHD, 2000) set the policy context for extended nurse prescribing in Scotland. As well as specifically making a commitment to expanding the scope of nurse prescribing, it set out the need to provide accessible, user-centred services for patients"
2.10 More recent literature on nurse prescribing in Scotland is limited and currently narrow in focus in contrast to literature relating to the UK as a whole, there is relatively little that relates to Scotland specifically (Mullally, 2003; Liley et al, 2005; McBeath, 1999). Two studies relate specifically to Scotland. Rodden (2001) explored the impact of nurse prescribing on autonomy and found that district nurses in Scotland prescribed more medication and were more autonomous practitioners than health visitors. Snowden (2006, 2007) recently conducted a pilot study in Scotland on nurse prescribing within the mental health sector which showed that registered mental health nurses differ from their colleagues in terms of attitude and experience of nurse prescribing and suggested that this may be a result of different approaches to the therapeutic relationship.
2.11 The research regarding nurse prescribing discussed in this chapter, highlights that it would be beneficial for more research, particularly in Scotland, on patients who had not received nurse prescriptions, patients who had received such prescriptions in different geographical and clinical settings, and further work on patient perceptions of services.
2.12 These gaps in knowledge therefore informed this project's research methods and data collection tools that we used e.g. the choice of case study locations and the work to collect patient and staff views across Scotland and different nursing groups.
2.13 The research reported here provides the first comprehensive view of nurse prescribing in Scotland. Some of these findings will also be applicable to prescribing across UK. This study also adds more information to the research on the views of patients and the public.
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