Non-medical prescribing: the doctor nurse relationship revisited Graham Avery, Jennie Todd, Gill Green, Katherine Sains This paper reports a study that was commissioned to evaluate nonmedical prescribing in one health authority in the south-east of England. A questionnaire was distributed to all nurses and pharmacists who held a non-medical prescribing qualification, and this was followed up by semi-structured interviews with nurses, pharmacists, doctors and managers. The findings confirmed that the majority of respondents were very experienced, and that they were making good use of the qualification. In addition, there were clear signs that patient care was being enhanced, but this was more evident when there was a close working relationship with the doctor. In the absence of this relationship, there is a need for the organisation to develop a clear strategy for the implementation of non-medical prescribing, which should incorporate the views of all key stakeholders. Background The Medicines Act 1968 allowed only doctors, dentists and vets to prescribe, and did not envisage that any other health care professional would ever need to prescribe. However, as Caulfield (2004) notes, it also failed to acknowledge that nursing practice would develop and that patients demands for rapid access to treatment would increase. The first official recognition that the Medicines Act was too restrictive to meet the demands of modern society came in 1986 with the publication of the Cumberlege Report (Department of Health and Social Services [DHSS], 1986). Since this time, non-medical prescribing has undergone a number of modifications (Department of Health [DH], 1999; Medicines and Healthcare Products Regulatory Agency [MHRA], 2003; MHRA, 2004; MHRA, 2005a; MHRA, 2005b), until the most recent legislation (DH, 2006b) which enables nurse and pharmacist prescribers to prescribe independently from the whole British National Formulary (BNF), with the exception of certain controlled drugs and unlicensed medications. The perceived benefits to be gained by the introduction of non-medical prescribing have been well documented (DH, 2001), and several authors have noted other factors that may have helped to force the initiative (Pearce, 2003; Sandars and Esmail, 2003; Chapman, 2004). Nevertheless, a number of studies suggest that nurses face an uphill struggle in their endeavour to become accepted as prescribers by patients (Harrison, 2003), pharmacists (Pleasance and Brownsell, 2004) and members of their own profession (Bradley et al, 2005). Most importantly, this qualification has the potential for bringing them into direct conflict with a powerful and vociferous group: the medical profession. When the British Medical Journal published a couple of articles that outlined government proposals to open up the whole BNF to nurses and pharmacists (Avery and Pringle 2005; Day 2005), the response was swift and strident, as the following quotations illustrate: How can one learn diagnosis and prescribing in depth with a few short courses? I think as doctors we undervalue our own profession if we think prescribing is so insignificant a skill or art if you prefer that it can be an add-on to a nursing degree. There will be an inevitable lowering of standards following this decision. Morbidity will increase, as will the cost of health care in general. (BMJ, 2005) It should be noted that these opinions are not universally held among the medical profession, but they illustrate the tension that results when changes in Graham Avery is Lecturer; Jennie Todd is Senior Research Officer; Gill Green is Professor of Medical Sociology; Katherine Sains is Clinical Pharmacist and Teaching Fellow, Department of Health and Human Sciences, University of Essex, Colchester Email: gavery@essex.ac.uk NP_5_3_doctor-nurse.indd 1 28/3/07 12:46:41
behaviour precede changes in attitude. In other words, the battle to secure extended prescribing rights may have been won, but the battle to win hearts and minds has only just begun. The extent to which this has been achieved might be a key factor in determining where non-medical prescribing is working well, and where it is falling short of expectations. Aim The study reported here was commissioned to evaluate non-medical prescribing in one health authority area in the south-east of England. In view of time, budget and ethical constraints, it could not (and, indeed, was never intended to) compete with the national study by Latter et al (2005), but was rather designed to add to the body of knowledge surrounding non-medical prescribing. It was also hoped that methodological variations between our study and the work of Latter et al would help to clarify outstanding issues regarding the benefits and barriers of non-medical prescribing in different health care settings. Design The participants were all nurses and pharmacists within one health authority area in the south-east of England who held a non-medical prescribing qualification (V200/300). Eligible participants (n=197) were identified by the education liaison managers and trust leads for non-medical prescribing and the chief pharmacists in each trust (13 primary care trusts; five acute trusts; and two mental health trusts). Data were collected in 2005 2006. A two-stage approach to data collection was adopted: phase one involved the distribution of an 18-item questionnaire, containing both closed and open questions, which collected survey-style information about the demographics of non-medical prescribers and the nature of their current prescribing practice. A separate section of the questionnaire asked respondents if they wished to be interviewed in phase two to discuss nonmedical prescribing in more detail. Those that agreed were asked to complete and sign a consent form and provide contact details, which enabled researchers to arrange an interview. In addition, the respondents were asked to pass a separate letter of invitation in a sealed envelope to their medical mentors in the hope that they too would agree to be interviewed. Fifty-four participants indicated their willingness to take part in an indepth interview, and those who were interviewed were selected purposively to include: those working in different regions of the county; representatives from primary, secondary, tertiary and mental health care; and those working in a variety of different settings (e.g. GP practice, district nursing, health promotion). Ethical approval for the study was obtained from a local research ethics committee covering the geographical area in which the research took place. Approval was also secured from each of the research and development committees for the respective trusts to ensure that the conduct of the study conformed to the protocols of research governance. Results Phase one: scoping exercise One hundred and ninety-seven questionnaires were distributed and a total of 85 were returned (nurses = 80; midwives = 3; pharmacists = 2). This represents a response rate of 43%, which is significantly lower than that achieved in the study of Latter et al in 2005 (71%). The demographic and professional details are outlined in Box 1 and Figure 1. The mean number of prescriptions written per day was six (range 0 35), whereas the number written per week was 11 (range 0 80). The main conditions for which nurses prescribed from the Independent Nurses Formulary are shown in Box 2. Phase two: interviews Of the 85 returned questionnaires, 54 (64% of respondents) agreed to be interviewed, and interviews were conducted with 16 nurses, five doctors, one prescribing pharmacist and three managers. From the data, it is possible to identify a number of themes, but this paper will focus on only one of these: namely, the relationship between the nurse and the doctor. Where there was a close working relationship between the doctor and the non-medical prescriber, full use was made of the prescribing qualification: I have confidence in [the nurse] and she is experienced, and I have worked with her for a number of years I wouldn t object to her [being given access to] the whole BNF and allowing her to get on with it. (Doctor, primary care) This, of course, is possible in a GP practice and in certain other highly specialised areas. It is less likely in a secondary care setting, or when the nurse covers a wide area, and this goes some way to explaining why there has been a poor uptake of the non-medical prescribing course in acute hospitals. It also makes it clear that doctors remain the gatekeeper who decides how far the non-medical prescriber can expand his or her role. As one manager noted: Within the acute sector, the application of non-medical prescribing is very poor. In large part, this was because there was insufficient discussion with the doctors prior to implementation of this initiative. In consequence, they have limited understanding of its potential benefits, and nor have they given it their full acceptance. (Manager, secondary care) Where nurses are prescribing for patients in the community, the difficulties that they have in establishing relationships with a variety of GPs are compounded by the budgetary implications that are inherent upon this. As the GP practice will be picking up the bill for any medicines prescribed, many doctors will still feel the need to exercise a large measure of control. One nurse specialist who works with patients from a number of different areas encapsulated the frustration that she had experienced: I had one [GP] who didn t even want to hear about it [i.e. non-medical prescribing]. He said: Who insures you? I felt that he was saying I am only a nurse, so I am not to be prescribing for his patients; we will just leave things as they are. (Nurse, tertiary care) The nurse in this situation is restricted to making written commendations for NP_5_3_doctor-nurse.indd 2 28/3/07 12:46:41
Frequency 40 35 30 25 20 15 10 5 0 5-10 years 11-17 years 18-25 years 26+ years Figure 1. Length of time qualified in the profession. appropriate prescriptions to the doctor and this inevitably delays the initiation of treatment for the patient. As a close working relationship between doctor and nurse is much more difficult to achieve in a hospital than in a GP practice, an institutional strategy is required if nonmedical prescribing is to be successful in these settings. The evidence that this has been formulated, however, is difficult to find, as one manager noted: The introduction of this initiative was accompanied by a lot of pressure from the Department of Health on the trusts to push through as many nurses as quickly as possible. As a result, there was no time to formulate a clear strategy, and many nurses were pushed onto the course without any plan as to how they were going to make use of the qualification at the end. The exclusion of doctors from any planning process made it inevitable that nurses would have difficulty implementing this newly acquired skill. (Manager, secondary care) We can t get the basics right, and that is where the trust priority lies rather than making super-nurses. (Manager, secondary care) The data suggest that those nurses who have committed their time and effort to the course may feel very frustrated when they discover that systems are not in place to enable them to make use of the qualification: I am doing my best to make use of it, but it is difficult because all the policies and procedures are not set in the trust at the moment. (Nurse, mental health) Such sentiments will be familiar to those working in a large organisation, particularly where the lines of authority are not clearly drawn; but they obviously represent a considerable barrier to the implementation of non-medical prescribing, and there is a real danger that the enthusiasm of the nurses for driving the service forward will quickly become dissipated. Discussion This study was commissioned to evaluate how effectively non-medical prescribing was working within one health authority area in the south-east of England. In the process, it has replicated a number of findings by Latter et al (2005), and the overall impression gained is that nurses are generally making good use of the qualification. In addition, many doctors are willing to allow a degree of autonomy to these health care professionals within certain constraints. Without exception, all of the respondents interviewed for this study showed full awareness of their limitations and acknowledged the potential risks associated with prescribing. Extension of the formulary would release many of the restrictions that they had encountered, but they also recognised that they would only prescribe within the confines of their competence. Certainly, the figures for the age of the respondents and the length of time that they had qualified suggest that the stereotypical nonmedical prescriber is a mature and highly experienced professional. Those who speak of the perceived danger of nonmedical prescribing being put in the hands of mavericks must therefore acknowledge the demographic of prescribers. Notwithstanding this, however, nonmedical prescribing works most effectively when there is a close working relationship Box 1 Demographic and professional details Nevertheless, the trusts have now had 5 years to organise for non-medical prescribing, but the evidence suggests that it has still not acquired top priority. One manager in an acute setting was clear that the trust had more pressing demands upon its time: Gender Male: 6 (7%); Female: 79 (93%) Age Mean: 46.27 years; Range: 30-64 Primary care 56 (66%) Secondary care 14 (17%) Tertiary care 13 (15%) Mental health 2 (2%) NP_5_3_doctor-nurse.indd 3 28/3/07 12:46:42
Box 2 Conditions for which independent nurse prescribing was used Rank Condition No of nurses % 1 Skin 44 52 2 Urinary system 39 46 3 Female genital system 34 40 4 Eye 30 35 5 Oral conditions 28 33 6 Ear 27 32 7 GI conditions 24 28 8 Musculoskeletal 23 27 9 Respiratory 23 27 between the nurse or pharmacist and the doctor. In consequence, it works best in GP practice and less well in secondary care. There are probably two issues that emerge from this. The first is that, despite the increased autonomy and job satisfaction experienced by many nonmedical prescribers, there has to be an acknowledgement that doctors retain ultimate accountability for the patient. In other words, they will be the ones who decide the limits within which the nonmedical prescriber is allowed to practise. However unpalatable this may be to a number of health care professionals, it is only through recognition of this that non-medical prescribing has a chance to flourish. To put it another way, the nonmedical prescriber must ensure that they have full engagement and acceptance of the concept of non-medical prescribing by doctors before embarking upon this role. The absence of such acceptance will condemn the non-medical prescriber to continued frustration and an inevitable lowering of morale. Second, however, the non-medical prescriber should not be forced to deal with this situation alone. Certainly, within secondary care and mental health, there is a need for the organisation to develop a clearly defined strategy and protocols for the implementation of non-medical prescribing, and this strategy must include substantive input from doctors. Sending people on these courses without such a strategy simply defeats the object of the exercise, for students will be unable to apply the knowledge and skills that they have gained (DH, 2006a). During the course of a number of interviews, it became clear that institutional strategies were poorly developed, and had not fully engaged the medical profession. Yet the potential for patient benefit in both secondary care and mental health is enormous. For example, with the agreement of doctors, it ought to be possible to develop pathways of care for patients with chronic conditions, which would enable the non-medical prescriber to initiate, titrate and modify treatment, thereby ensuring both speed of access and enhancement of quality care. Similarly, nurses emerging from the course should be proficient in the skills of safe and effective prescribing, and they would be in a position to facilitate the development of these skills in junior doctors. Finally, the organisation must ensure that it carefully selects those who it sends onto the course. The organisation must be able to identify that there are going to be clear advantages to patients before sending people for non-medical prescribing training, and it must have a clear strategy and support system at an organisational and local level for ensuring that the practitioner will be able to make use of the qualification. Study limitations As with all studies, there are a number of limitations. Perhaps the most important is the fact that those who completed the questionnaire and came forward for interview tended to be those who were satisfied with how non-medical prescribing was working. This was not entirely the case with this study, for a number of interviewees highlighted significant problems that they had experienced and voiced their frustrations with the process. The response rate to the questionnaire was low (43%), in spite of follow-up of non-responders, and during the course of this study, it was possible to develop some insight into the reasons for this. It may have been because the potential respondent had only recently qualified and was not yet in a position to prescribe; it is also possible that there are certain areas of practice where non-medical prescribing is failing to be established, and, in consequence, is having no impact upon practice. Conclusion The general impression gained during this research was that non-medical prescribing was having a significant impact upon practice in certain areas, and that its use would be expanded further once full prescribing rights had been granted. However, the study also uncovered a number of barriers to successful implementation in other areas, and consideration needs to be given to addressing these. None of these barriers are insurmountable, but they require a commitment from all stakeholders if the potential benefits of non-medical prescribing are to be fully realised. References Avery AJ, Pringle M (2005) Extended prescribing by UK nurses and pharmacists. BMJ 331: 1154 1155 British Medical Journal (2005) www.bmj.com/cgi/ eletters/331/7526/1159 (accessed 21 March 2007) Bradley E, Campbell P, Nolan P (2005) Nurse prescribers: who are they and how do they perceive their role? J Adv Nurs 51: 439 448 Caulfield H (2004) Legal aspects, responsibility, accountability in nurse prescribing. Prescribing Nurse Spring: 20 23 Chapman S (2004) ORCA: a new tool for the review of medication in asthma management. Nurse Prescribing 2: 20 25 Day M (2005) UK doctors protest at extension to nurses prescribing powers. BMJ 331: 1159 4 NP_5_3_doctor-nurse.indd 4 28/3/07 12:46:42
Department of Health and Social Services (1986) Neighbourhood nursing: a focus for care. Report of the Community Nursing Review (Cumberlege Report). Department of Health, London Department of Health (DH) (1999) Review of Prescribing, Supply and Administration of Medicines (Crown Report). DH, London DH (2001) Patients to Get Quicker Access to Medicines. Press Release Notice. DH, London DH (2006a) Improving Patients Access to Medicines: a Guide to Implementing Nurse and Pharmacist Independent Prescribing Within the NHS in England. DH, London DH (2006b) A Prescription for Patient Satisfaction. Press Release. DH, London Harrison A. (2003) Mental health service users views of nurse prescribing. Nurse Prescribing 1: 78 85 Latter S, Maben J, Myall M, Courtenay M, Young A, Dunn N (2005) An Evaluation of Extended Formulary Independent Nurse Prescribing. Final Report. DH, London Medicines and Healthcare Regulatory products Agency (MHRA) (2003) MLX 293. Nurse Prescribers Extended Formulary: Proposals to Extend the Range of Prescription only Medicines. MHRA, London MHRA (2004) MLX 303. Nurse prescribers extended formulary: proposals to extend the range of prescription only medicines. MHRA, London MHRA (2005a) MLX 320. Consultation on Options for the Future of Independent Prescribing by Extended Formulary Nurse Prescribers. MHRA, London MHRA (2005b) MLX 321. Consultation on Proposals to Introduce Independent Prescribing by Pharmacists. MHRA, London Pearce L (2003) A prescription. Nurs Stand 17: 14 5 Pleasance G, Brownsell M (2004) Improving communication between nurse prescribers and community pharmacists. Nurse Prescribing 2: 171 173 Sandars J, Esmail A (2003) The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract 20: 231 236 Key Points Non-medical prescribing has undergone significant changes in recent years, but the pace of change has created some opposition to this initiative. More use was made of the prescribing qualification when there was a close working relationship between the nurse and doctor. Where a close working relationship had not been established, there was a need for the creation of an organisational strategy to enhance the implementation of non-medical prescribing. 5 NP_5_3_doctor-nurse.indd 5 28/3/07 12:46:43