Barriers and enablers to nurse prescribing in primary care

From its inception in the early 1990s, non-medical prescribing (NMP) has grown and developed at a rapid rate in the UK. It has evolved from an initially small number of community nurses and health visitors, prescribing from a limited formulary, to the current situation where a significant and growing number of nurse independent prescribers (NIPs), pharmacists and an increasing range of allied health care professionals (AHCP) are permitted extensive prescribing rights that are only limited by their scope of expertise. The UK is viewed as a world leader in NMP because of the short training programme, extensive roll-out and lack of prescribing restrictions (Smith et al, 2014; Nuttall, 2017). The rise of NMP has been driven by the need to improve patient care and access to medicines, make better use of the skills of health professionals, and to promote more flexible working in the health service (Department of Health and Social Care, 2012). NMP has been beneficial to the healthcare system, patients and prescribers through up-skilling the workforce (Darvishpour et al, 2014). Research indicates that NIPs are both safe and well-evaluated by medical colleagues and patients (Graham-Clarke et al, 2018).

An accredited course must be successfully completed before nurses can register as a prescriber with their professional regulatory body, the Nursing and Midwifery Council (NMC, 2016). The Single Competency Framework (SCF) for all prescribers was published by the National Prescribing Centre and the National Institute for Health and Clinical Excellence (NICE) in 2012. This has been superseded by an updated version, published the Royal Pharmaceutical Society (RPS) in 2016, which sets the standards for all prescribers, not just nurses. The SCF has been adopted by the NMC to replace their previous guidance.

Despite this robust framework, noticeable variations still exist in the utilisation of the prescribing qualification, with some NIPs choosing to only prescribe in a limited way or not prescribe at all (Nuttall et al, 2017; Graham-Clarke et al, 2018). All prescribers face significant challenge due to a aging population with increasing co-morbidities and complex polypharmacy requirements; keeping abreast of new drugs and the potential interactions means that prescribers need to actively develop and maintain their competence to prescribe (RPS, 2016), which can stretch the boundaries of their scope of practice.

Therefore, the focus of this study is to understand the practices and challenges for NIPs working in primary care (PC), as suggested by the key identified literature. These insights can be factored into the planning and delivery of future education to help facilitate the needs of learners working in PC and to optimise prescribing practice. This could enhance the individuals' prescribing practice for both new and more experienced NIPs.

Methods

The key words/terms chosen for this search were:

• Nurse prescribing
• Non-medical prescribing
• Prescribing nurse
• Primary care.

Using the Exeter University database, the above terms were used to search Medline Ovid (15 studies identified), Cinahl (12 studies) and Pubmed (eight studies). In addition, a Google Scholar search was carried out. Key policy documents were identified including the SCF (RPS, 2016) and Standards of Proficiency for Nurses and Midwife Prescribers (NMC, 2016). No grey literature was identified, despite consulting with local non-medical prescribing leads and the lead for the regional NMP training programme. From this search, the five papers listed (see Table 1) were selected for this literature review. Two meta-syntheses and one systematic review were selected for their high rank in the hierarchy of evidence and the aggregation of findings and synthesise of themes from many smaller studies. Various methods were used to assess and rate the quality of the papers. Darvishpour et al (2014) rated the studies in their meta-synthesis with an overall grade of moderate to strong using AMSTAR and the Critical Appraisal Skills Programme (CASP) tool (2017). Nuttall et al (2017) graded their studies as ‘strong to moderate’ using the Downes' Quality Assessment tool. Graham-Clarke et al (2018) used the 16-point quality assessment tool for studies of diverse design (QATSDD) and used all the studies, despite varying degrees of quality. The two remaining studies were a national cross-sectional survey of NIPs and NMP leads and a qualitative study using semi-structured interviews and focus groups. The author examined these papers using the CASP tool (2017). All the papers were read and those that addressed the question were selected for their relevance based on the author's experience in this field of practice. An exclusion date of prior to 2014 was set due to the rapid expansion and evolving nature of NMP in PC. Other papers were excluded due to duplication or due to inclusion in the above meta-synthesis and systematic review. Papers that were not representative of NIPs working in PC, such as those reporting an pharmacists or nurses working in narrow specialist fields, were excluded.

Results

Following analysis of the literature, three main themes were identified by the author: support, continuing professional development (CPD) and organisational factors (Table 2).

The NMP training programmes and the support from the designated medical practitioner (DMP) were deemed sufficient, as NIPS felt adequately prepared to practice (Smith et al, 2014). Weglicki et al (2015) argues that whilst the generic programme covers the core underpinning principles of safe prescribing, it may not meet the varied needs of individual prescribers who practice across a vast range of different specialities; hence the necessity for further education and support beyond the initial training. Smith et al (2014) noted that most NIPs working in primary care, with a notable exception of community nurses and health visitors, reported good levels of continuing professional support with access to an experienced prescriber, personal development plans, regular appraisal and access to the NMP network. The influence and support of the DMP both during and after training was identified by all the studies as a powerful enabler, and the absence of such support was a prominent source of anxiety and a limiting factor for prescribing. A lack of understanding about the training and role of NIPs by some doctors was found to be a barrier (Darvishpour et al, 2014). Those doctors who provided clinical supervision as a DMP were more likely to provide ongoing support (Graham-Clarke et al, 2018). The PC team benefited as a result of NMP through greater collaboration and improved interprofessional relationships with colleagues; a closer working relationship was forged between NIPs and pharmacists (Nuttall, 2017).

The literature highlights the benefits to the individual NIP, which include improved autonomy, greater job satisfaction and career development. However, lack of remuneration and professional recognition, increased workload and lack of support were the negatives identified as barriers (Graham-Clarke et al, 2018). Fear of litigation as a result of prescribing errors or failure to maintain competence as dictated by the RPS (2016) was a commonly identified concern. Lack of retention of the theoretical knowledge underpinning prescribing and fears about not keeping up to date with their area of competency were often expressed (Weglicki et al, 2015). Clear definition of the scope of practice and boundaries was used to ensure safe practice. NIPs were more likely to closely follow formularies and guidelines, compared to doctors. Two of the papers found that boundary setting and adherence to formularies helped to build prescribing confidence, but could also limit prescribing if too rigidly adhered to especially for patients with multi-morbidity (Nuttall, 2017; Graham-Clarke et al, 2018). Additionally, prescribing for patients with comorbidities and for the very young and old caused anxiety (Nuttall, 2017).

CPD is clearly essential to the professional development of NIPs but could be hindered by lack of protected time, workloads, budget constraints and lack of support from managers (Graham-Clarke et al, 2018). NIPS working in PC experienced difficulties accessing updates and CPD (Nuttall, 2017). One-third of NMP leads working in both primary and secondary care who were questioned in the cross-sectional national survey felt the provision of CPD was inadequate and could affect patient safety (Smith et al, 2014). Various methods of maintaining CPD were described by the studies: peer support, study days and courses, journals, textbooks, guidelines and e-learning. The preferred mode of CPD varied, with some NIPs indicating face-to-face education because of the interaction with teachers and peers. However, this tended to be more expensive and it was often difficult to get away from work, hence others stated a preference for e-learning as a solution to these issues (Weglicki et al, 2015). A blended learning approach, combining taught study days and e-learning materials, was proposed as an answer (Weglicki et al, 2015).

The NMC (2016) stipulate that clinical governance, clinical and managerial support, and agreed protected learning should all be in place, prior to nurses commencing NMP training. However, the literature alludes to organisational barriers, such as lack of time, excessive administration, increased workloads, time pressure, lack of access to notes, prescription and technology (Graham-Clarke et al, 2018). Lack of access to electronic data and computer decision aids was reported, however this was less of a problem for NIPS working in PC, compared to those working in the acute sector (Smith et al, 2014). Prescribing leads reported a lack of means to monitor NMP and prescribing data; systems for reporting poor performance were less commonly used in primary care (Smith et al, 2014). Electronic prescribing analysis and cost data (ePACT) data was more commonly available in PC to monitor prescribing by NIPs (Smith et al, 2014). Lack of forward planning was also identified with an example of this being the potential impact on service provision if there was no backfill for clinics/services, which depended on NIPs to run (Smith et al, 2014).

Discussion

As the number of prescribing nurses, pharmacists and AHCPs grows at an ever-increasing rate, problems linked to access to CPD, support and organisational infrastructure continue to hamper prescribing practice. Further research is necessary to permit NIPs to develop and expand their prescribing, and to allow this vital service to flourish. Currently there is a lack of NIP research relating to education (Nuttall, 2017), cost effectiveness (Darvishour et al, 2014) and patient experience (Smith et al, 2014).

Smith et al (2014) found that the barriers and the facilitators to prescribing were similar for NIPs working in PC and the acute sector. This is surprising because NIPs working in PC are almost always direct employees of the GP and the business that they own, compared to those working in secondary care who are part of and employed by a large organisation. The nature of PC is rapidly changing, with greater collaboration between practices and the growth of primary care network groups. This could offer greater opportunities and support for individual NIPs working in PC, as well as strategic opportunities for managers to plan for future expansion of NMP and further development of the infrastructure to support this.

The three overarching themes of education, support and the organisation cannot be addressed in isolation as they co-exist and impact on each other. Weglicki et al (2015) argues that nurses who were self-motivated to undertake NMP training were unlikely to succeed without the support of management. Doctors and managers must be fully invested in supporting NIPS and facilitating CPD. NIPs are responsible for their own learning and CPD (RPS, 2016). Nuttall (2017) found that some NIPs perceived that it was their responsibility to seek out and access CPD while others viewed this as their employer's responsibility: CPD is cleared of shared obligation for NIPs and their employers. Meeting the challenges of varying CPD requirements of NIPs in the context of pressured workloads and limited budget requires new and innovative ways of working, which might include both face-to-face and e-learning. As a strategy to address the increasing demands on PC, practices are broadening their skill mix and employing pharmacists and other practitioners. Two pharmacists have recently been employed at the author's practice, resulting in enhanced support for NIPs on pharmacology and safe prescribing. Additionally, they have also delivered training sessions on polypharmacy and medication reviews.

Successful completion of NMP training is only the start of the journey: for NIPs to fully utilise this qualification and develop this role, an individual professional development plan and a network of support is required, along with assessment of competence, appraisal and feedback. The SCF provides an ideal model to address the individuals learning needs, whether a new learner or an experienced NIP, and can be used at any stage of practice to guide best prescribing practice (RPS, 2016). Strategically, the SCF provides a guide to facilitate the design and delivery of the education programme. As an educator for LTCs in PC, incorporating the principle of SCF into planning and delivery of education will address the prescribers' learning outcomes, which have been identified in the literature as both specific to the speciality and to reviewing the principles of safe prescribing.

Conclusion

The barriers and enablers for NIPs working in PC are closely linked and relate to continuing professional development, support and the organisation. The individual NIP, their employers, educational institutions and providers need to devise novel ways of addressing the identified need to update and develop both clinical and prescribing practices. Systems to support and develop NIPs and monitor practice must be embedded in their workplace. The development of PCNs provides an opportunity for practices to work together, share resources, build a sound infrastructure to support NIPs in practice, and to collaborate on workforce planning for future expansion of NMP.

Key Points

• Nurse independent prescribing in primary care can be facilitated through education, clinical support and a clearly defined role in the workplace
• Organisational factors, such as managing workload, systems for monitoring performance and future workforce planning, are essential to providing and promoting nursing independent prescribing
• Accessing a range of CPD resources covering safe prescribing practice, pharmacology and management of patients with multi-morbidities will enable nurse independent prescribers to develop and expand their practice

CPD reflective questions

• How can the ongoing educational needs of nurse independent prescribers be best met and can multi-disciplinary education sessions in the work place facilitate this?
• How can primary care networks support and develop nurse independent prescribing in primary care?