Scottish Government

Main Findings

• The review indicated broad support from patients and professionals for the use of different models of prescribing and supply of medicines in which health professionals adopted a wider prescribing role.
• There was evidence of improved patient access to medicines and services as a result of nurse prescribing, the use of patient group directions and the direct supply of medicines by pharmacists.
• Patient safety was not measured specifically but was implicit in some studies' outcomes, for example, the overall satisfaction with which patients and nurses viewed nurse prescribing implied that it was safe. However, evidence for the safety of patient group directions was inconclusive.
• Patients and nurse prescribers in several studies reported benefits of nurse prescribing, e.g. timeliness of treatment and improvements in the quality of care.
• Nurse prescribers identified two main continuing professional development needs, education and support, as necessary for safe and effective prescribing. In some areas, continuing professional development was either underdeveloped or non existent.
• Some nurses and patients felt nurse prescribing led to better use of GPs' and nurses' time as nurses dealt with minor problems freeing GPs to deal with more serious cases.
• The direct supply of medicines by pharmacists effectively transferred GP workload associated with minor illness to community pharmacists in three pilot studies. However, there was no overall decrease in GPs workload.
• There was concern that pre-registration nurse education may not prepare nurses adequately for the medicines management role that the nursing profession expects of them on registration.

Background

The focus of current Government policy is to improve health, reduce health inequalities and to promote social justice by improving patient access to health care services. Role developments within the NHS workforce are tailored to meet these policy aims and objectives by making best use of professionals' skills and time. Examples of role expansion to improve patient access to medicines are nurse prescribing and the direct supply of medicines by pharmacists.

Aims and objectives

The aim of the literature review was to provide a critical and comprehensive review of research literature on prescribing both in the United Kingdom and in countries with comparable health care systems from 2000 _ 2003. The specific objectives of the study were to examine:

• the impact of different approaches to prescribing on the quality of services provided by health professionals, identifying any public safety issues
• the impact of changing models of prescribing on patients' access to medicines
• the impact of changing prescribing roles on health professionals' workloads
• the adequacy of current training requirements and arrangements in prescribing

Method

Whilst not a full systematic review, this review used the same methodological principles. A replicable search strategy was developed to interrogate electronic databases, yielding a total of 8805 potentially relevant studies. Inclusion criteria were rigorously applied to the identified studies and publications that met the inclusion criteria were abstracted onto individual summary sheets. Methodological comment was offered on each study.

Results

Although there was relatively little research published from 2000-2003 in areas addressed in the review and the quality of the studies included varied, the findings identified a number of themes that can be used to:

• provide context for the planned evaluation of the extension of nurse prescribing
• inform debate around key issues such as patient safety and educational preparation for a prescribing role
• suggest areas for further work

44 publications reporting on 41 studies were included. The findings fell into three categories; education and training, the impact of prescribing models on patient care and the impact of prescribing models on professionals.

Education and training

The findings indicated that appropriate education and training were essential not only for safe and effective prescribing but also for a wider role in medicines management. This applied to pre-registration education and to continuing professional development for qualified doctors and nurses. The review failed to identify studies that focused on either initial or further education for pharmacists. The educational and support requirements of nurses and pharmacists within the extension of nurse prescribing and the introduction of supplementary prescribing may be considerable. Identification of their learning needs and subsequent evaluation of the educational provision will be essential to ensure safe and effective practice.

The impact of prescribing models on patient care

Four prescribing models were identified in the literature; prescribing by doctors and nurses, patient group directions which enable patients to receive medicines from certain health professionals in the absence of an individualised prescription, and the direct supply of medicines by pharmacists. The advantages of nurse prescribing related more to access and the delivery of care rather than safety and effectiveness. Patient group directions, not all of which met legal requirements, were used widely and included antibiotics. This contradicts government advice which advocates the selective use of patient group directions and in particular antibiotics because of wider public health concerns about antimicrobial resistance. The extension of nurse prescribing has the potential to reduce the need to use patient group directions in settings where access to individualised prescriptions issued by doctors has been limited. Nurse-led services enabled patients access to same day care in general practice, and opportunities for nurses to take on prescribing authority under the extension of nurse prescribing could offer a more consistent and comprehensive service. Improved patient access to treatment also resulted from schemes allowing community pharmacists to supply certain medicines to patients directly.

The impact of prescribing models on professionals

The impact of prescribing models on the volume and balance of professionals' workload was unclear. In schemes where community pharmacists supplied medicines directly to patients, GPs transferred workload to pharmacists but did not experience a corresponding reduction in their overall workload. This may have been because freed up time was used to respond to previously unmet needs within the practice. Some nurses found that nurse prescribing led to time saving but most felt that there was additional work associated with record keeping and administration. Nurses, doctors and pharmacists cautiously welcomed prescribing developments, but identified the importance of appropriate education. They also advocated a restricted or supervised form of prescribing by professionals other than doctors rather than independent prescribing. Supplementary prescribing by nurses and pharmacists fits this suggested model.

Conclusion

Although there was relatively little research published in the last three years in any of the areas which were addressed in the review, and the quality of the studies included varied, the results of the review identified a number of themes that can be used to:

• provide a context for the planned evaluation of nurse prescribing
• inform the debate around key issues such as patient access to services, patient safety and educational preparation of health professionals
• suggest areas for further work

Overall, there was support from patients and professionals for adopting different models of providing medicines other than by traditional doctor prescribing. However, there was no evidence of a systematic or strategic approach to the selection of the most appropriate prescribing model to meet patients' needs. More work is required to evaluate the safety of all prescribing models and the appropriateness of their use in particular clinical settings. All nurse prescribing research related to district nurse and health visitor prescribing within a primary care setting. No work has yet been published to evaluate the extension of nurse prescribing whereby nurses and midwives prescribe from a wider formulary and across a range of care settings.

There was very little research which focused on education although the results of this did raise concerns about the adequacy of educational preparation for prescribing and other medicines related roles. Further research is required to give an accurate indication of the impact of education on prescribing practice. This is particularly relevant now that new educational programmes to prepare nurses for extended independent nurse prescribing and nurses and pharmacists for supplementary prescribing have been introduced.

The findings suggest there is scope for:

• further research to evaluate the impact of different models of prescribing on patient care, including patient safety and on professionals' role development. Research is needed to evaluate the impact of the extension of nurse prescribing and the effectiveness of educational preparation for the prescribing role
• NHS organisations to use a critical and systematic approach in selecting prescribing models which best suit patient need in different clinical situations
• a more judicious approach to the use of patient group directions. This may require NHS organisations to review existing patient group directions against legal requirements and provide multidisciplinary education to ensure professionals are equipped to draw up patient group directions and use and record them accurately
• assessment of the continuing professional development (CPD) needs of all prescribers undertaken by NHS organisations. This could inform the development of systems to support CPD.
• higher education institutions to review the content and delivery of subjects that underpin prescribing and medicines related practice such as pharmacology in pre-registration nurse education