Nurse prescribing in general practice: a qualitative study of job satisfaction and work-related stress

Transcription

1 Family Practice 2012; 29: doi: /fampra/cmr077 Advance Access published on 28 September 2011 Ó The Author Published by Oxford University Press. All rights reserved. For permissions, please Nurse prescribing in general practice: a qualitative study of job satisfaction and work-related stress Rosanna Cousins* and Christine Donnell Department of Health Sciences, Liverpool Hope University, Liverpool, UK. *Correspondence to Rosanna Cousins, Head of Health Sciences, AEW208, Liverpool Hope University, Taggart Avenue, Liverpool L16 9JD, UK; cousinr@hope.ac.uk Received 1 March 2011; Revised 31 July 2011; Accepted 22 August Background. Studies examining the impact nurse prescribing have largely focused on the efficacy of the service. It was suggested in pro-prescribing policy arguments that extending the nursing role to include prescribing would increase job satisfaction. This assertion has not been fully explored. Objectives. To investigate the impact of independent prescribing for experienced nurse practitioners (NPs) working in general practice. Methods. In-depth interviews were conducted with six NPs who each had at least 3 years experience of independent prescribing in a busy inner city general practice. Results. Analysis of interview data yielded two main themes: as independent prescribers NPs experienced increased levels of both job satisfaction and work-related stress. Increased satisfaction was associated with having greater autonomy and being able to provide more holistic care. Increased work-related stress emerged from greater job demands, perceived insufficient support and perceived effort reward imbalance that centred upon the enhanced role not being recognized in terms of an increase in grade and pay. Conclusions. Independent prescribing increases job satisfaction for NPs in general practice, but there is also evidence of stressors associated with the role. It is important that NPs in general practice are encouraged and supported towards providing the effective patient-centred care in the community envisaged by current UK government. We acknowledge that the results presented in this paper are based on a sample limited to one city; however, it provides information that has important implications for the well being of NPs and ultimately patient care. Keywords. General practice, job satisfaction, nurse prescribing, qualitative, work-related stress. Introduction The introduction of nurse prescribing in the UK in 1992 was underpinned by recommendations of the Department of Health advisory group report; 1 known as the first Crown Report, it included various supportive clinical arguments and additionally asserted there would be an increase in job satisfaction for nurses. Job satisfaction is old construct that has stood the test of time. It is a combination of psychological, physiological and environmental circumstances that cause a person to assert that they are satisfied with their job. 2 It assesses the difference between an individual s expectations, and what he or she actually experiences. Such a definition indicates a variety of variables that influence the satisfaction of the individual. So, although job satisfaction is a unitary concept, the causes of this overall attitude are multidimensional. 3 There is general support for the premise that prescribing increases job satisfaction for nurses. 4 6 However, extant studies have largely focused on the positives, without due consideration of any negative aspects, there may be in taking on the extended role. The nursing profession is known to have high prevalence rates of work-related stress, 7,8 and potentials for stress in general practice have also been documented. 9 It is estimated that nurses now have almost the same prescribing rights as doctors in the UK, 10 although the number of nurse-independent prescribers in general practice has not reached predicted levels. 11 A recent survey in one English county indicated that <20% of practice nurses managing chronic conditions held a nurse prescribing qualification 11 despite evidence that many GPs are positive about nurse prescribing, and patients are both satisfied and confident 223

2 224 Family Practice The International Journal for Research in Primary Care in being treated by a nurse prescriber There are no studies that are specific to nurse prescribing in general practice to explain the relatively low numbers of nurse practitioners (NPs) who are also independent prescribers. The aim of this study was to investigate the full impact of becoming an independent prescriber for NPs in general practice. In addition to confirming Crown s assertion that independent prescribing increased job satisfaction, we additionally explored whether the extended role made a difference to potentials for stress in NPs. Methods Design A qualitative approach was chosen. This was most appropriate towards teasing out the longitudinal element of the research. In-depth semi-structured interviews were used to collect rich data describing the context, perceptions, actions and emotions of participants in relation to job satisfactions and dissatisfactions in relation to nurse prescribing in general practice. Sampling Six NPs who were also experienced independent prescribers were interviewed (five females and one male; aged years). All had held the qualification Registered General Nurse (RGN), for at least 10 years, and, in line with the inclusion criteria of the study, all participants had held the qualification V300 independent and supplementary nurse prescribing for at least 3 years. All the participants were autonomous practitioners, running their own clinics in one of the four separate sites of a group practice in Liverpool, UK. Full clinics and issuing several computer-generated prescriptions during each clinic was the norm. All the practice clinics operate during the hours 8:30 18:30 under a booking system; additionally, the one site purposely serving the large student community in the city has a walk-in clinic during the hours 8:30 16:00 during term-time. While the sample size is small, it is representative of the number of NPs meeting the criteria in the city. This type of study often includes a small cohort. 15 Additionally, there is some confirmation of the sufficiency of a sample size of six for a qualitative study, 16 and here, there was evidence of reaching saturation after six interviews. the advantages/what do you enjoy about being a prescriber? and What are the disadvantages/difficulties of being a prescriber? A digital voice recorder was used to aid transcription, and additionally, contextual notes were made by the interviewer. The data were fully transcribed and then analysed using content thematic analysis. Inter-rater reliability was checked. There is no easy way to ensure the reliability or objectivity of judgement-based nominal data: the best approach relies on the evaluation of the judgements of two or more independent coders. 17 In this study, transcripts of the six interviews were first coded in full by the authors and then another independent experienced researcher agreed to read all six transcripts and code the data (Consent was obtained from all participants prior to sharing the data.). Holsti s formula 2m/N1 + N2 18 was applied to determine the inter-rater reliability. This was calculated >80%, allowing the data to be considered reliable. The disagreements were resolved by reference to the field notes and the interviewer s judgement. Results Four themes were identified from the interview data: benefits of nurse prescribing, which had three subthemes increased control, greater autonomy and more holism in role; increased job demands, support issues and lack of reward. Further reduction of the data produced two overarching concepts: increased job satisfaction and work-related stress. Benefits of nurse prescribing Autonomous practice was found to be pivotal to the enhanced job satisfaction reported by all six NPs who were also independent prescribers Figure 1. Being able to complete an episode of care for the patient, which previously would not have been possible if a prescription was required, was key. Before becoming qualified independent prescribers, at the very least, the NPs would have had to have a GP sign off even routine repeat prescriptions. NP2 stated It s just that it makes my job easier. The fact that I can give patients medications, I can give them what they need rather than Data collection and analysis Individual semi-structured interviews of up to 2 hours were undertaken with the NPs in their homes, at a time of their convenience. The interviews explored the changes in their job since becoming independent prescribers; indicative questions included How has your job changed since becoming a prescriber?, What are FIGURE 1 Themes from content analysis of interview data

3 Nurse prescribing in general practice 225 consult with someone else. I enjoy that, treat them myself rather than get someone else to do it for me, I enjoy that. Similarly, NP3 answered I enjoy it because I can finish the whole consultation; because I don t have to wait for other people to finish the care and I think I give the best service to the patient. NP3 suggested that a patient has got a lot more faith in you if you can tell them you need to be taking this, rather than saying, I ve just got to go and check with the doctor. It undermines the whole consultation if you ve got to go and get your prescription signed. The NPs were all positive about the prescribing role, perceiving it as enabling them to provide a more holistic and complete type of care. For example, NP1, a sexual health expert, said I get more job satisfaction now because I can instigate treatment or first pills. If the patient is coming for the pill, I can prescribe it and see them again. It has given me more autonomy. The narratives strongly suggest that independent prescribing increases NPs confidence and self-esteem, which in turn increases their job satisfaction. All six participants clarified that they prescribed only within their own competencies, not stepping outside of them despite pressure to do so from both patients and GPs. Prescribing within one s competencies ensures safe prescribing and also ensures that practice is in line with current NMC guidelines contained within the NMC Code of Professional Conduct. 19 This is important within any sphere of clinical practice; however, it is of particular importance to NPs as independent prescribing is a relatively new role for them. When prescribing NPs need to address medicolegal issues; prescribing when not in a position of competence would not only be potentially dangerous to patients but also indefensible should any harm occur. Being able to professionally delineate their competencies for prescribing increased confidence as NPs became more experienced, which in turn increased job satisfaction, and for some participants an expressed increase in self-esteem. There was consensus among the NPs that they could not go back to a non-prescribing role. Considering before becoming a prescriber and her current position NP3 said I couldn t stand outside a GP s door after doing all the training. I d be offended that I couldn t use it. It would downgrade the whole role and I think nurse prescribing gives you some kudos. And as NP5 observed, the patients are aware of your skills and they know you re making decisions and prescribing for them. It gives you a sense of satisfaction. Autonomy, holism and increased job control were recognized as advantages of the independent prescribing role by all six NPs, with nurse prescribing in turn leading to a perceived increase in patient satisfaction, which was also important to all the participants. Increased job control was highlighted many times in conjunction with the provision of holistic care and appeared to be an important positive aspect of prescribing. To reiterate, all participants stated that they enjoyed the autonomy of the prescribing role; however, increased job control was generally referred to in terms of the completion of an episode of care and the absence of the need for medical input. As NP6 noted with approval, I don t have to wait outside doctors doors anymore. I think it validates independent thinking. The main advantages arising from the prescribing role appear to be an overall increase in job satisfaction, which results from the ability to complete care autonomously and holistically. This involves a high amount of job control, with nurses assessing, diagnosing and treating independently. Other factors contributing to increased job satisfaction are the enhanced status enjoyed by nurse prescribers and the increase in self-esteem, which arises from patient recognition of the nurses enhanced skills and respect from colleagues. Lack of rewards The increased intrinsic rewards described above, were not, however, supplemented by increased extrinsic rewards. All six participants clarified that NPs who go on to qualify as independent prescribers do not move up to a higher grade and are not rewarded financially. Participants felt aggrieved that the effort of attaining the qualification and the increased responsibility associated with independent prescribing has not been recognized by the UK Government s Agenda for Change documentation, 20 which outlines the pay, terms and conditions for the National Health Service (NHS). The salary banding for NPs does not include recognition for those working in a prescribing role. As NP1 reported I m on the same grade now as I was on four years ago and didn t prescribe. This is going to be a difficult issue to resolve in the current climate of cuts in the NHS, but there was the suggestion in this study that the lack of increased grade and pay is a barrier to some NPs becoming independent prescribers and is a factor in losing independent prescribers in general practice to the profession. The effort reward imbalance model 21 argues that stress arises where there is a belief that the efforts invested in a job are not appropriately rewarded, and there was some evidence in support of this in the experience of interviewing and the narratives. Participants felt under-rewarded as independent prescribers in general practice. Critically, there were perceptions of a mismatch of effort and reward, which is known to be related to burnout, de-motivation, stress and anxiety. 21,22 Increased job demands Changes in job demands since becoming prescribers included the management of more complex patients, the need for more knowledge and the need to continually update knowledge, perceived lack of sufficient consultation time to deal with the more complex needs of the patients, increased responsibility associated with diagnosing and prescribing and the pressure to prescribe.

4 226 Family Practice The International Journal for Research in Primary Care Time constraints were an issue for participants, with the main problem being consultation time given to nurses for appointments. In line with the recent call from the Royal College of General Physicians for minute appointments, 23 participants felt that in their specialty 10 minutes for an appointment was insufficient especially as this was the same time for a consultation as before they were prescribing. Job control is decreased by the time constraints and where job demands are perceived as excessive and not matched by reward, individuals can feel undervalued and the imbalance between effort and reward increases. This can result in individuals becoming de-motivated, stressed and in some cases depressed. 21 Participants expressed feelings of frustration and stress during interviews and some stated that they were having difficulty coping with their workload in the allotted time. This was exacerbated by the pressure to prescribe from both medical staff and patients. Participants suggested that the expectations of GPs and patients have changed since they have become used to having nurse prescribers, with both groups expecting nurses to prescribe on a par with doctors. NP5 argued I don t think all our colleagues are clear about non-medical prescribing. Also, patient expectations can cause problems. It can be hard to persuade them that they don t actually need a prescription. This causes pressure and takes up consultation time. Pressure to prescribe was a major demand on all the participants and the frequency of the occurrence of this aspect of the job demand subtheme was much greater than any other aspect. One nurse, felt this acutely, and when asked by whom, stated by patients, by people in the practice GP s reception. I think, once the receptionist says I ll put you in with the nurse, she s a prescriber; the patient gets angry if it s something like an anti-depressant which I m not going to prescribe. That s probably the biggest challenge. It was clear that misunderstandings around the nurse prescribing role has led to patients being given inappropriate appointments by receptionists, which in turn, angers patients and causes more pressure for nurses. Nurses in this position need to refer to practice colleagues and this lack of control, in the face of high job demands is stressful. All the participants confirmed that working as an independent prescriber affords a significant increase in clinical responsibility, and with experience, awareness of the increase in clinical responsibility develops. The extra responsibility combined with the pressure to prescribe and lack of consultation time caused participants to feel stressed during busy clinics and support was recognized as important. Need for support Perceived lack of support was an issue for all the participants and several sources were identified, including the medical staff, professional bodies, such as the Royal College of Nursing and nurse colleagues. Participants were particularly concerned about the need for support with professional development and updating. Updating is a statutory requirement for nurses and is essential in the maintenance of clinical competence, but there is a lack of a formal system for updating. NP2 recalled No. I haven t had a prescribing update. Even trying to get an update on how to use your British National Formulary, any new drugs, is difficult. However, at one site, they had been proactive: we ve tried to set up a little forum for the nurses once a month, where we can go through issues and we check on the new guidelines. We go on the website to find out what new drugs are out, the side effects, etc. Discussion The study sought to extend the current literature by using a sample of experienced NPs working in general practice who were interviewed in depth about changes in their job since they qualified as independent prescribers. The study is limited in so far as the sample size was relatively small and confined to one city. Nevertheless, the quality of the data is rich and robust enough to warrant the findings being reported. Moreover, we would suggest that the findings have implications for practice and policy makers. The findings from this research are in agreement with earlier studies and add clarity to the picture. Experienced NPs made an overall evaluation that becoming a prescriber had increased their job satisfaction; however, not all aspects of the job were better. The participants in this study were all positive about prescribing and stated that the benefits were such that they would not be prepared to go back to working in a non-prescribing clinical role. Satisfaction resulted from the new ability to complete care autonomously and holistically, alongside an increase in respect from patients and some colleagues; the increase in work-related stress arose from perceived work overload, pressure to prescribe and a lack of support towards professional development. Lack of remuneration for the increased clinical responsibility also led to a perceived sense of unfairness. The effort reward imbalance model 21 purports that where work demands are high but are matched by a high levels of job control and reward and then individuals perceive a sense of satisfaction and work is experienced as a positive activity. The themes emerging from the interview data support Siegrist s model, and additionally suggest that although NPs, who were also independent prescribers, had perceptions of effort reward imbalance, while stressful, 22 these were not sufficient to outshine the increased satisfaction experienced in the vocational aspects of the job-increased autonomy and holistic patient care. Nevertheless, this is a matter for concern for general practices, in terms of efficacy and duty of care for employees.

5 Nurse prescribing in general practice 227 In conclusion, this sample of NPs judged that overall, there was an increase in their job satisfaction since becoming an independent prescriber, in line with Crown s assertion. 1 This, however, has to be tempered by increased potentials for work-related stress. If numbers of nurse prescribers are to be increased in general practice, which remains a government objective, then potential stressors need to be managed. Given the current economic situation in the UK, nurse-independent prescribing is unlikely to be upgraded; nevertheless, there are benefits for nurses becoming independent prescribers and these need to be highlighted. Managers should also be clear that no additional remuneration is guaranteed, and similarly that role descriptions are clear. Additionally, nurse prescribers should be included in relevant practice management meetings and fully supported in terms of continuing professional development. Declaration Funding: The authors confirm that no funding was received to support this study. Ethical approval: Liverpool Hope University Research Ethics Board. Conflict of interest: none. References 1 Department of Health. Report of the Advisory Group on Nurse Prescribing (Crown Report). London: DoH, Hoppock R. Job Satisfaction. New York, NY: Harper, Kalleberg AL. Work values and job rewards: a theory of job satisfaction. Am Sociol Rev 1977; 42: Bradley E, Nolan P. Impact of nurse prescribing: a qualitative study. J Adv Nurs 2007; 59: Bradley E, Campbell P, Nolan P. Nurse prescribers. Who they are and how they perceive their role? JAdvNurs2005; 51: Lewis-Evans A, Jester R. Nurse prescribers experiences of prescribing. J Clin Nurs 2004; 13: Cox T, Griffiths A, Cox S. Work-Related Stress in Nursing: Controlling the Risk to Health. Geneva, Switzerland: International Labour Office, 1996; Working Paper CONDI/T/WP. 4/ McVicar A. Workplace stress in nursing: a literature review. J Adv Nurs 2003; 44: Calnan M, Wainwright D, Forsythe M, Wall B, Almond S. Mental health and stress in the workplace: the case of general practice in the UK. Soc Sci Med 2001; 52: Courtenay M, Carey N. Nurse prescribing by children s nurses: views of doctors and clinical leads in one specialist children s hospital. J Clin Nurs 2008; 18: Kelly A, Neale J, Rollings R. Barriers to extended nurse prescribing among practice nurses. Community Pract 2010; 83: Watterson A, Turner F, Coull A, Murray I. An Evaluation of the Expansion of Nurse Prescribing in Scotland. Document prepared on behalf of Scottish Government Social Research, (accessed on 12 August 2011). 13 Brooks N, Otway C, Rashid C, Kilty L, Maggs C. Nurse prescribing: what do patients think? Nurs Stand 2001; 15: O Connell E, Creedon R, McCarthy G, Lehane B. An evaluation of nurse prescribing. Part 2: a literature review. Br J Nurs 2009; 18: Krippendorff KH. Content Analysis: An Introduction to its Methodology, 2nd edn. Thousand Oaks, CA: Sage Publications, Inc., Guest G, Bunce A, Johnson L. How many interviews are enough?: an experiment with data saturation and variability. Field Methods 2006; 18: Perreault WD Jr., Leigh LE. Reliability of nominal data based on qualitative judgements. J Marketing Res 1989; 26: Holsti OR. Content Analysis for the Social Sciences and Humanities. Reading, MA: Addison-Wesley, Caulfield H. Vital Notes for Nurses: Accountability. Oxford: Blackwell Publishing Ltd, Department of Health. Agenda for Change Final Agreement PublicationsPolicyAndGuidance/DH_ (accessed on 12 August 2011). 21 Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol 1996; 1: Bakker AB, Killmer CH, Siegrist J, Schaufell WB. Effort-reward imbalance and burnout among nurses. JAdvNurs2008; 31: Royal College of General Practitioners. Leading the Way: High Quality Care for all Through General Practice: A Manifesto for Patient Care (accessed on 12 August 2011).