The
Internet Journal of Healthcare Administration 2008 :
Volume 5 Number 2
Effects
Of Nurse Prescribing Of Medication: A Systematic
Review
Lotti M. Van Ruth MS
Nivel Netherlands Institute For
Health Services Research
Patriek Mistiaen RN, MSN
Nivel Netherlands Institute For
Health Services Research
Anneke L. Francke RN, PhD
Nivel Netherlands Institute For
Health Services Research
Citation: L. M. Van Ruth, P. Mistiaen
& A. L. Francke : Effects Of Nurse Prescribing Of Medication: A Systematic
Review . The Internet Journal of Healthcare
Administration. 2008 Volume 5 Number 2
Keywords: Nurse prescribing | Drugs prescription |
Systematic review
Abstract
Background :Nurse prescribing is
being implemented increasingly. This article reviews the literature on the
effects of it.
Methods :Eleven databases and 6 websites were
searched. The quality of the studies was determined. Outcomes were classified
by the effects on medication prescribed, on patients, on professionals and on
the health care system.
Results : Twenty-three studies were included.
All but two studies had a high risk of bias. Nurses sometimes differ from
physicians in the number of patients they prescribe or in the choice of type of
medication. Clinical parameters were the same or better for treatment by
nurses; perceived quality of care by nurses is similar or better. The effects
on professionals or on the health care system could not be described.
Conclusion :The effects of nurse prescribing
seem positive, although the high risk of bias in the studies means they must be
regarded with caution.
This work was funded by the NIVEL
Background
Nurses can legally prescribe medication in several
countries nowadays, e.g.
Other parties see potential drawbacks to nurse
prescribing in the form of a higher risk of prescription errors, over-prescribing
and incorrect diagnosis that will threaten patient safety and potentially
damage the health of patients, e.g. (7,8).
Nuzzo (1998 page 45) states that “Non-supervised
prescribing authority wielded by independent nurse practitioners does present a
greater possibility for a drug disaster” and “there is an increased risk to the
public health” (9).
Others stress that supplementary nurse prescribing in particular (i.e. nurse
prescribing under the supervision of a physician) will lead to a reduction in
errors (10).
There is a lack of systematic knowledge, however, on
the effects that nurse prescribing has had to date (2).
Although several literature reviews have been published on nurse prescribing,
most reviews focus on the characteristics of nurse prescribing, the
implementation process of nurse prescribing, or its legal implications. Very
few reviews focus on the effects of nurse prescribing in practice and those
reviews that did focus on the effects of nurse prescribing have limitations. They
lack clear methodology, are narrative reviews in stead of systematic reviews,
or have restricted the studies they include on the grounds of publication years
or country (5,11,12,13).
The purpose of this systematic review is to review the
effects of medication being prescribed by nurses.
The following four research questions have been
formulated with regard to effects:
What are the effects of nurse prescribing compared to
physician prescribing, on the quantity and types of medication being
prescribed? What are the effects of nurse prescribing on patient outcomes? What
are the effects of nurse prescribing on physician and nurse outcomes? What are
the effects of nurse prescribing on characteristics of the health care system?
What is nurse prescribing?
Buchan and Calman (2004)
discern three categories of nurse prescribing, viz. independent, supplementary
and by group protocols.
Independent nurse prescribing, also known as initial,
autonomous or substitutive prescribing, refers to a
nurse being able to prescribe the type and dose of medication without the
supervision of a medical practitioner.
Supplementary prescribing, also called dependent,
collaborative, semi-autonomous or complementary prescribing, means that a nurse
works with a supervising independent prescriber, usually
a physician.
The third category is prescribing through the use of
group protocols. The group protocols, also called patient group directions,
allow nurses to administer medications subject to the terms of a predetermined
protocol for a particular group of patients (2).
A category called “approaching” independent nurse
prescribing was added in this review, in order to describe situations in which
a nurse is fully responsible for the choice of type and doses of medication,
but a physician still signs the prescription without seeing the patient. The
nurse does not have formal prescriptive authority in this case, but studies
with this form of nurse prescribing were nevertheless considered relevant to
this review.
Methods
The systematic review was conducted in five phases,
viz. the search for relevant studies, selection of relevant studies, quality assessment of the studies included, data extraction
and data synthesis.
Search for relevant studies
To identify all relevant studies up to February 2006 a
sensitive search was performed in the following eleven literature databases and
six relevant websites, viz. Pubmed, Embase, Cinahl, Cochrane Library,
Picarta, SCI, Invert, Biomed
central, Virginia Henderson Library, Current Control Trials and NIVEL catalog, the website of the UK Department of Health
(www.doh.gov.uk), the website of the World Health Organisation (www.who.org),
and other websites for health professionals (www.nurse-prescriber.co.uk, www.escriber.com).
Google (www.google.com) was also searched.
The search was highly sensitive using the following
search terms for the database PubMed:
(“Nurse prescribing”) OR (Nurs*
[tiab] AND Prescri* [tiab]) OR (Nurs* AND
prescriptions, drug [MeSH])
Comparable search strategies were used in the other
databases (the specific search strategies are available on request). References
cited in the reviews of the effects of nurse prescribing were also collected (5,11,12,13).
There was no limitation on the searches by country, language or year of
publication.
Selection
Studies with all sorts of patients were included. There
was no restriction on the type of patients for whom medication was being
prescribed; all studies in which nurses had actually prescribed medication for
patients were included, with the exception of group protocols for child
vaccination or travel vaccination. Furthermore, studies were only included if
they had a comparative design, e.g. comparing nurse prescribing to physician
prescribing, or comparing nurse prescribing over time. All studies had to be
empirical research, others such as letters, abstracts, reviews and editorials
were excluded. All studies included had to report on the effects of nurse
prescribing. The selection of studies was not limited by the types of
effects.
A total of 8851 non-duplicate references were found
(see figure 1).All references found in the literature search of databases and
websites were initially studied by title and abstract by one reviewer and were
included when they met the aforementioned criteria. A second reviewer took a
10% sample from these and agreement with the first reviewer was analysed. High
agreement (95% and Cohen's kappa = 0.60) meant that the first reviewer
completed the first selection round alone, in which 125 of the 8851 studies
were included on the basis of the selection criteria.
Figure 1: Flow diagram of
the inclusion process
All articles were studied independently on a full text
basis by both reviewers in the second selection round. Differences were
discussed until both reviewers agreed on inclusion or exclusion, and a third
reviewer was called in to decide if necessary.
Both reviewers agreed that 23 of the 125 studies met
the inclusion criteria.
Quality Assessment
All studies were assessed independently by both
reviewers on methodological quality. Differences were resolved by consensus,
with a third reviewer if necessary. The EPOC, which is the data collection
checklist of the Cochrane Effective Practice and Organisation of Care Review
Group, was used to determine the methodological quality. The EPOC includes
seven quality criteria that studies have to meet (see table 1).
Table 1: The criteria of
the EPOC list used to determine quality of the studies with score options
A study was judged as having a low risk of bias if it
met all seven criteria, a moderate risk of bias if it met four, five or six
criteria, and a high risk of bias if it met three criteria or less (14).
This list is only applicable to RCTs, CCTs, Controlled before and after
studies and interrupted time series designs. Other designs, such as
pre-experimental post-test only designs, were regarded as having a high risk of
bias, since these have a general low evidence strength
when studying the effects of interventions.
Data extraction
Data was extracted from each relevant study by the
first reviewer using a pre-designed table (see Appendix 1), and the data were
subsequently checked by the second reviewer. All data extracted from the
studies were based on the results sections and not on the conclusions of the
study.
Data synthesis
The outcomes were grouped together into effects on
medication being prescribed (e.g. number of patients being prescribed
medication, quantity of medication being prescribed, type and dose of
medication being prescribed), effects on patients (e.g. quality of care,
satisfaction with care, clinical parameters for patients), effects on
professionals (e.g. workload, time savings) and effects on the health care
system (e.g. accessibility of care, cost of care).
Pooling
Pooling of outcomes was considered if studies reported
similar outcomes, presented raw data and had either all continuous or all
dichotomous outcomes. Standardised mean differences and a random effects model
were used for continuous outcomes, while relative risks and a random effects
model were used for dichotomous outcomes. Confidence intervals were set at 95% (15).
The decision to pool studies was based on their clinical homogeneity, according
to similarity in the care setting and in the type of illness affecting the
patients included in the study. Furthermore, the results of the poolings are only reported when the pooled studies showed
acceptable statistical homogeneity. Studies were considered to be statistically
homogenous when the chi-square test value was lower than the degrees of
freedom, the P value was above 0.1 and the inconsistency test I2 was
lower than 50% (15,16).
Subgroup analysis
Subgroup analysis was considered for country and type
of nurse who was prescribing. Although sensitivity analysis on the basis of the
methodological quality of the studies was considered, this was not carried out
since almost all studies had a high risk of bias.
Subgroup analysis was not attempted for the category
of nurse prescribing, because these categories are mostly not clearly stated in
the studies and have to be deduced from the setting, type of nurse who is
prescribing, year of publication and country. The categories of nurse
prescribing were not used as a basis for subgroup analysis, therefore, and are
stated to give an indication of the different forms of prescribing included in
the review.
Results
A total of 23 studies were eventually included in this
review. The methodological quality assessment of the 23 studies included will
be given first, followed by their characteristics and ending with the effects
of nurse prescribing on medication being prescribed, on patient outcomes, on
physician and nurse outcomes, and on characteristics of the health care system.
The effect on the percentage of patients for whom medication was being
prescribed was the only factor appropriate for pooling in this review. For this
factor a sub-group pooling was done for country. Other poolings
were not appropriate, due to the large clinical heterogeneity or large
statistical heterogeneity of the studies. No other subgroup-poolings
were possible by country or by type of nurse prescriber.
Methodological quality assessment
Only seven of the 23 studies included were Randomized
Controlled Trials (RCTs) (17,18,19,20,21,22,23),
and one was a Controlled Clinical Trial (CCT) (24).
The other studies had pre-test post-test designs without a comparison group, or
pre-experimental post-test only designs. All of these other studies, non-RCT or
non-CCT, have an inherently weak methodological evidence base for establishing
effects and were rated as having a high risk of bias as a consequence.
The eight studies using a randomised or non-randomised
controlled design were reviewed on methodological quality using the EPOC
checklist. None of the RCT or CCT studies met all the criteria; two studies had
a moderate risk of bias (18,19),
while the other studies had a high risk of bias because less than four of the
criteria on the EPOC list were met.
Characteristics of studies included
Seven of the 23 studies involved independent nurse
prescribing, one study involved supplementary nurse prescribing, five studies
described a mix of independent and supplementary prescribing, and five studies
looked at prescribing by group protocols. Five studies showed “approaching”
independent nurse prescribing.
The publication years of the selected studies varied
from 1974 to 2005. Seven of the 23 studies were conducted in the
Primary care
Ten of the sixteen studies that were conducted in primary
care involved nurses prescribing for various patients (21,22,23,24,25,26,27,28,29,30);
one focused only on patients with acute minor illnesses (31),
and three studies included only patients with sore throats or upper respiratory
throat infections (32,33,34).
There was one study in primary care of patients with diabetes (18)
and one study of women seeking contraceptive services (17).
In these primary care studies, nurse practitioners, physician assistants,
nurse-midwives or community nurses were prescribing a variety of medication or
antibiotics and diabetes-related medication in one case.
Secondary care
Three of the seven studies carried out in secondary
care were conducted in the field of mental health care and involved patients
with a diagnosis of schizophrenia, depression, dysthemia
or bipolar II disorders (35,36,37).
Three studies involved patients with diabetes (19,20,38)
and there was one study in a radiotherapy and oncology department, which
involved patients with diagnoses that included acute radiation toxicity causing
proctitis from pelvic radiotherapy, and erythema of the scalp due to cranial irradiation (39).
Advanced practice psychiatric nurses with prescriptive authority (APRNs) prescribed psychotropic drugs, diabetes specialist
nurses prescribed insulin, and clinical nurse specialists prescribed antifungal
preparations, mouth care lotions, etc.
Effects on medication prescribed
Number of patients being prescribed medication
Nine out of eleven studies report that the number of
patients for whom a nurse prescribes medication is similar to or lower than the
number for whom a physician prescribes. Two studies show nurses prescribing
medication for a higher percentage of patients than physicians do (see Table
2.). These eleven studies will be discussed below in more detail.
Several studies in primary care in the UK found no
differences in the percentage of patients that had a prescription issued by
nurses or by general practitioners (21,23,24,31).Two
studies also found no difference between nurses and general practitioners
regarding the percentage of patients being prescribed antibiotics for sore
throats or viral upper respiratory tract infections (33,34),
while one study in secondary care also found no difference in the percentage of
patients being prescribed anti-depressants (35).
Table 2: Number of
patients being prescribed medication by nurses versus physicians/psychiatrists
Two studies found that nurses prescribed medication
for fewer patients than physicians did (25,32).
Batey & Holland (1985), however, only report the
percentage of patients being prescribed for by nurses (49.7%) and by physicians
(63%), but do not report whether this difference is statistically significant. In
contrast to the findings described above, two studies found that nurses
prescribed medication for more patients (27,30).
Hooker & Cipher (2005) found no difference in the overall number of
patients being prescribed for, but when rural areas alone were taken into
consideration, they found that nurse practitioners prescribed medication for
significantly more patients than physicians did, whereas physician assistants
wrote the fewest prescriptions (27).
Sub-analysis
A pooling of studies concerned with the number of
patients being prescribed medication was only possible for 6 studies that
reported raw dichotomous data and were conducted in a primary care setting with
various patients. This pooling has not been reported here due to substantial
statistical heterogeneity. Analysis of a subgroup of this pooling per country,
however, shows that four studies in the UK taken together show no difference in
the number of patients being prescribed medication by nurses and GPs (see
figure 2) (21,23,24,31).
This is in contrast to two other similar studies (primary care setting and
involving various patients) that were conducted in the
Figure 2: Number of
patients being prescribed medication in primary care in the
Total quantity of medication being prescribed
Four studies report that nurses prescribed a similar
or lower total quantity of medication overall, compared to physicians or
psychiatrists. One of these also reports that nurses prescribe more medication
than physicians or psychiatrists in some cases (see Table 3).
Table 3: Total quantity
of medication being prescribed by nurses versus physicians/psychiatrists
A study of nurse prescribing in primary care in the
Fisher et al. (2003) found in secondary mental health
care that psychiatrists prescribed a total quantity of 155 medications and
advanced practice registered nurses 119, although this difference was not
statistically significant. Two studies in mental health care found that
psychiatric nurses, on the whole, prescribed less benzodiazepines for anxiety (36,37).
Jacobs (2005) also found they prescribed less mood stabilizers, less secondary
anti-depressants and less new-age antipsychotic medication than psychiatrists. A
minimal difference in the prescription of selective serotonin reuptake
inhibitors (SSRIs) was found. Furthermore, Jacobs
(2005) found that differences in medication prescription between psychiatric
nurses and psychiatrists also depended on type of therapy. Where split therapy
was concerned (when psychotherapy is separate from medication management), the
prescription of benzodiazepine anti-anxiety agents was slightly greater in
patients being prescribed by psychiatric nurses (20%) than in those being
prescribed by psychiatrists (15%). In the case of other types of therapy, the
prescription of mood stabilizers and secondary anti-depressants by psychiatric
nurses and psychiatrists was similar. Both studies (36,37),
however, did not clearly report the statistical significance of the above
findings.
In the field of diabetes care, the quantity of
medication prescribed by specialist nurses and medical specialists were the
same for glucose and blood pressure lowering medication. The specialist nurses
prescribed a significantly lower quantity of cholesterol lowering medications (20).
Number of medications being prescribed per patient
visit
Two studies reported on the number of medications
being prescribed. One study found that the mean number of medications
prescribed per patient during a visit was similar for physicians, physician
assistants and nurse practitioners (27),
while another study found that the average number of medications used by
patients is 1.33 per medication visit for nurse prescribing, compared to 1.87
for physician prescribing (25).
The statistical significance of this finding was not reported.
Type of medication and dose prescribed
There were few overall differences in types of
medication and doses prescribed; two studies in mental health care for patients
with depression and schizophrenia reported mostly similar types of medication
prescription by nurses and psychiatrists (35,36).
One study of family planning reported several differences in type of
medication, but no differences in clinical outcomes (17).
Drug selection within a therapeutic class was mostly
similar for psychiatric nurses and psychiatrists, with anti-depressant
medications being prescribed most frequently (35,36).
Although SSRI anti-depressants were prescribed most
frequently by both groups, nurses preferentially prescribed SSRI
antidepressants, whereas psychiatrists prescribed more types of antidepressant
medication other than SSRI. Benzodiazepines were prescribed in similar
proportions (36).
Furthermore, Feldman et al. (2003) found no difference
between the groups where adult therapeutic dose was concerned, although
psychiatrists more often augmented and switched medication and titrate doses. Psychiatric
nurses had fewer patients with concomitant sedatic/hypnotic
medication use or a combination of central nervous system stimulants.
A study in a family planning clinic found that nurses
inserted fewer intrauterine devices (IUDs), were more likely to keep the client
on conventional methods, and prescribed more temporary methods until the next
visit. It is unclear whether these differences are statistically significant.
The number of patients to receive IUDs on their next visit was similar for
nurses and physicians. Clinical outcomes for patients (reported later) were the
same (17).
Effects on patient outcomes
Clinical parameters
Most of the nine studies reporting on clinical
parameters of patients found no differences between prescribing nurses and GPs
and some found that the patients who were given prescriptions by nurses had
better clinical parameters (see table 4).
There were no significant differences between patients
being treated by a nurse or by a GP in the resolution of symptoms and concerns (24);
in patients' rating of their health status or in terms of clinical improvement
after two weeks (21);
in health status outcome (23);
in the number of sore throats that had settled (33);
in the physical status level, emotional function and social function, and crude
death rates (22);
and in pregnancy rates, method continuation and side effects for contraceptive
services (17).
Table 4: Clinical
outcomes of patients being prescribed by nurses or physicians
Cox and Jones (2000) found that the median number of
days for a sore throat to settle was lower for nurses' patients than for GP
patients. Furthermore, patients' perception of being back to
normal health were more favourable for nurses.
A study of diabetes care found that there was a 22%
reduction in hypoglycaemic events compared to the period before nurse
prescribing, that no errors or adverse events occurred as a result of nurse
prescribing, and 74% of the target population experienced improved glycaemic control or symptomatic relief or both. Staff
members stated that care had greatly improved. The statistical significance of
these findings was not reported (38).
Houweling (2005 ch.4 and
ch.5) conducted two studies in the field of diabetes care and found no
significant differences in clinical outcomes, quality of life or
diabetes-related symptoms (as perceived by patients) for patients being treated
by practice nurses or diabetic specialist nurses compared to a GP or a medical
specialist (18,19),
with the exception of the cholesterol/HDL ratio, which improved more for
patients being treated by a medical specialist in the secondary care setting (19).
Satisfaction with care
Eight studies all found that patients being treated by
nurses were just as satisfied or more satisfied than patients being treated by
physicians (see table 5).
Table 5: Differences in
patient satisfaction with care by nurses or physicians
Four studies in primary care found that satisfaction
with the health care received was similar (22,24,31,33)
and two studies found that patients were more satisfied with care received from
nurses compared to care received from GPs (21,23).
Kinnersley et al. (2000) found in three of the ten
practices researched that adult patients were more satisfied with care received
from the prescribing nurses and that children were also more satisfied in
general.
Furthermore, two studies conducted in the field of
diabetes care found that patients were more satisfied with care provided by the
prescribing nurse than by a physician or medical specialist (18,19).
Patient enablement
Two studies report that patient enablement, i.e. the
extent to which patients understand their illness and are able to cope, is
similar for nurse practitioners and GPs (23,31),
although health visitors have better results in this respect than either nurse
practitioners or GPs (31).
Quality of care
Three studies in primary care report that quality of
care provided by nurses is similar to or better (in some cases) than that
provided by GPs.
The first study is by Spitzer et al. (1974), who found
no significant differences between nurses and GPs in quality of care or in
adequate prescription of drugs (assessed by criteria pre-developed by group of
physicians) for the 2058 families included in the research.
The second study, by Luker
et al. (1998), reports that nurses are considered to be in a better position to
prescribe than GPs in some fields, due to a unique knowledge of patients and
their circumstances, and the expertise of the nurses in activities such as
wound management and baby care.
A third study in primary care for diabetes patients
showed that all process indicators for quality of care were better for nurses
than physicians, except for intensifying glucose level lowering therapy or intensifying
cholesterol reducing therapy, for which there was no difference (18).
Consultation time
Six of the seven studies reporting on consultation
times found that nurses generally spent more time with patients and one found
no difference.
Three of the studies that found that nurses had longer
consultation times than GPs were conducted in the
Two studies in secondary mental health care in the USA
found that psychiatric nurses spent more time with patients during medication
visits (36)(37),
although Jacobs (2005) does not report the statistical significance of this
finding.
A study in primary diabetes health care in the
Information and documentation
Three studies report that prescribing nurses give
either more or the same amount of information to patients and that
documentation is similar.
Nurses were found to give more advice than GPs about
home remedies (33),
self-medication and general self-management (21).
Kinnersley et al. (2000) found that nurse
practitioners gave similar amounts of information in seven practices, but
patients managed by nurse practitioners in three of the ten practices reported
receiving more information about their illnesses.
Documentation of clinical records in mental health
care was not qualitatively different for advanced practice psychiatric nurses
compared with psychiatrists (35).
Investigations, referrals and reconsultations
As will be discussed below, several studies show that
the number of investigations by nurses is similar or higher than by GPs and
that there are no differences in referrals to secondary care. Most studies show
no difference between nurses and GPs where reconsultation
rates of patients are concerned.
One study in primary care found that that nurses were
more likely to initiate investigations (23,31),
whereas another study found that GPs were more likely to initiate
investigations (31).
Venning et al. (2000) also found that the number of
patients that had a physical examination was similar and Kinnersley
et al. (2000) found no difference between nurses and GPs in the number of
investigations done.
Three studies in primary care reported no differences
between nurses and GPs in the number of referrals to secondary care (23,24,31).
A study of patients with diabetes in secondary care found that more patients of
the specialist nurse were referred back from the hospital to treatment by their
GP (primary care) than was the case for patients of the medical specialist (19).
Four studies in primary care found no differences
between patients of nurses and patients of GPs where reconsultations
were concerned (24,31,32,33).
Venning et al. (2000), however, found that nurses
asked patients to return more often and that patients treated by nurses were
more likely to make a return visit to the clinic. A study on contraceptive
services showed that nurses have significantly more scheduled revisits for
method changes and less unscheduled revisits (17).
A study in primary diabetes care reported that the total number of
consultations by patients was higher for nurses than for GPs (18).
Only two of the seven studies reporting reconsultation results could be pooled on reconsultations (Butler et al, 2001 and Cox & Jones,
2000). The studies show no significant effect when taken separately, but pooled
together they show that nurses have slightly more reconsultations
than GPs. The risk of reconsultation is low (between
6% –10%) for GPs and nurses, however, and the effect size found is a minor one
(1.68, confidence level 1.04 –2.73).
Adherence to medication prescription
Only one study in mental health care reported on
adherence to medication and found no significant difference between being
treated by a psychiatrist or by an advanced practice registered nurse (37).
Effects on professional outcomes
Workload reduction and time savings
Only three studies investigated professional outcomes
of nurse prescribing with regard to workload reduction and time savings.
One study reported that the workload of the GP had been
reduced, with 13% of the urgent appointments now being managed by a practice
nurse or health visitor with prescribing tasks. It is unclear whether this is a
statistically tested and significant finding (31).
Two studies reported time savings due to nurse
prescribing. One study reported that the independent treatment of some patients
(102 of the 206) by a prescribing practice nurse saved the GPs a total of 2825
minutes (about 47 hours) over a period of fourteen months. If all patients had
been treated by a practice nurse, the GPs would have had to spend a total of
536 minutes (about nine hours) discussing consultations with nurses in the
fourteen–month period (18).
Ferguson et al. (1998) reported a mean weekly time saving of one hour per
district nurse and a mean weekly time saving of 50 minutes per GP.
Effects on costs and other characteristics of health
care system
Accessibility of care
Four studies show positive effects of nurse
prescribing on accessibility of health care. The perceived benefits of nurse
prescribing reported by all four studies are greater accessibility and
approachability, such as reduced waiting times in obtaining medication, and
reduction of the number of health professionals to be seen by the patient (28;29,38,39).
Luker et al. (1997) also reported reduction in the
number of journeys some carers had to make, earlier start of treatment, and
that clients felt more able to discuss concerns with nurses. Some disadvantages
were reported in the form of dissatisfaction with new methods of obtaining
prescriptions (28).
The statistical significance of all the above findings
is unclear.
Costs
Four studies that report on the health care costs of
nurse prescribing show either no difference in costs or some (potential) cost
savings of nurse prescribing compared with prescribing by another clinician. These
studies will be discussed in more detail below.
Venning et al. (2000)
found that there was no significant difference in health service costs between
nurse practitioner prescribing and GP prescribing in primary care general
practices.
The second study, by Ferguson et al (1998), which used
eight scenarios to compare the actual costs of nurse prescribing with the
estimated costs had nurse prescribing not been introduced, showed that the
introduction of nurse prescribing at the practices had resulted in net savings
on six scenarios. Net increases in costs emerged in only two scenarios. The
outcomes, depending on best, neutral or worst scenarios, range from net savings
of 158,653 pounds to net costs of 82,841 pounds (26).
The statistical significance of these findings is unclear.
Spitzer et al. (1974) stated that their study showed
that nurse practitioner care (including nurse prescribing) was cost-effective
from society's point of view, but not financially profitable for doctors,
because of the restrictions on reimbursement for nurse practitioner services at
that time.
Finally, the study by Houweling
(2005c) in diabetes care in the
Conclusion and Discussion
The overall effects of nurse prescribing seem
positive.
Nurses mostly prescribed medication for a similar or
lower percentage of patients than physicians did, although caution is advisable
here, since two studies actually showed that nurses prescribed medication for a
higher percentage of patients than physicians did. Although nurses sometimes
seem to differ from physicians in their choice of the kind of medication
prescribed, the overall health care outcomes for patients prescribed for by
nurses compared to patients prescribed for by physicians were positive;
clinical parameters were the same or better for treatment by nurses, quality of
care by nurses is similar or better and patients treated by nurses were just as
satisfied or more satisfied. The results also show that consultation times are
similar or more commonly longer for prescribing nurses, that they give either
more or the same amount of information, that the number of investigations by
prescribing nurses is similar or higher than by GPs, and that there are
generally no differences in referrals to secondary care or reconsultation
rates. These results are consistent with the results of a review by Horrocks et al. (2002) of care provided by nurses compared
to physicians. Horrocks et al. (2002) found in a
meta-analysis, however, that nurses carried out more investigations.
The anticipated benefits for professionals, in the
form of workload and time savings, or for the health care system with regard to
accessibility and costs, cannot be confirmed because of a lack of substantial
comparative research in this area. Available results show a potential
improvement in accessibility of health care, but there is scarcely any evidence
of potential reductions in workload, or savings on time or costs. No research
was found to report on the following anticipated benefits referred to in the
introduction, viz. better use of the skills and experience of nurses,
recognition of their competences and expertise, and improved working
relationships between health care professionals.
Considering the methodological quality of the studies
reviewed, the effects of nurse prescribing on all outcomes can only be seen as indications
of possible effects and conclusions must be approached with caution. Doubts on
overall safety and damage to patients' health have not been confirmed, however.
As yet, no reasons have been discovered why nurses should not prescribe under
certain conditions, but the question of whether nurse prescribing delivers all
the anticipated benefits needs to be explored by further research.
Limitations
One limitation of this review concerns the fact that
nurse prescribing in the studies reviewed was embedded in other tasks, such as
consultation, diagnosis and treatment. It is difficult to distinguish nurse
prescribing from these other tasks and focus solely on
the effects directly resulting from nurse prescribing, and so it remains
unclear to what extent the effects found are the direct result of nurse
prescribing or are more the result of the entire task substitution of
physicians by nurses. Horrocks et al (2002) suggest
in their review comparing care provided by nurses with care provided by
physicians that the factors that lead to greater satisfaction should be
elucidated, such as the extra consultation time, the consultation skills of
nurses, or patients' expectations. Longer consultation time or greater skill on
the part of the nurses may lead to greater patient satisfaction, regardless of
whether the nurse is also prescribing medication (40).
Another limitation relates to the fact that the
heterogeneity of the research made it difficult to make a general comparison of
the studies included. The studies considered various different categories of
nurse prescribing, various settings and various patients, were done in various
countries and, last but not least, used various outcomes and outcome measurements.
Although the results mainly point in the same direction, they are difficult to
compare.
Furthermore, it must be taken into account that the
methodological quality of the studies included was generally very poor for
determining the effects of nurse prescribing. With the exception of two studies
with a moderate risk of bias, all of the studies had a high risk of bias and
the results of this review must therefore be viewed with caution. They can only
be regarded as studies that provide indications of existing effects on
medication prescription, patients, professionals and the health care system,
and the evidence for the reported outcomes is weak as a consequence.
It must also be taken into account that most results
for the quantity and type of medications being prescribed by nurses and
physicians are not directly linked to the clinical outcomes, potential
medication errors or adverse effects on patients, and so it is unclear whether
similar, smaller or greater quantities of medication being prescribed, and
similar or different choices of type of medication result in adequate, better
or worse care. Ladd (2005), for example, shows that even though the prescribing
of antibiotics is not appropriate for viral upper respiratory tract infections,
both nurses and physicians prescribe similar numbers of patients
antibiotics for this condition. Studies that did assess the clinical
appropriateness of prescribing by nurses found that the nurse prescribed
appropriately (41,42).
Furthermore, the results of the pooling seem to
indicate possible differences in nurse prescribing between countries, although
this result could also be caused by differences in prescribing categories, by
differences in the type of nurse who is prescribing, or by possible differences
in design between the studies. These results need to be viewed with caution,
especially since there are only 2 studies from the
Further research
Future research, preferably using randomised
controlled designs, is needed to obtain more evidence on all effects of nurse
prescribing, and specifically the effects of nurse prescribing on professionals
and on the health care system. More research is needed on potential differences
or similarities in medication adherence, quality of care, consultation time,
information, investigations, referrals and reconsultations,
and these should preferably be studied in combination with their effects on
(clinical health) outcomes for patients, for professionals and for the health
care system as a whole.
Future research should also indicate whether
differences in the type of medication being prescribed have any implications
for clinical health outcomes or how the quantity of medication being prescribed
affects the health care system in its entirety, by demonstrating possible cost
per year per practice for example.
Attention is also required for the consequences that
differences between nurses and physicians in the type of medication being
prescribed may have for the appropriateness of prescribing, potential adverse
effects, or medication errors.
Appendix 1: Data
extraction table of all included studies. This table presents a summary of all
included studies on design, country, setting and type of patient, nurse
prescribing, number of patients, risk of bias and results.
Acknowledgements
The authors wish to acknowledge the assistance and
support of Ms Noor Breuning,
a librarian at the NIVEL, for her help with the execution of the search
strategy.
Corresponding author
NIVEL
3500 BN Utrecht
The
Phone: +31302729700
Fax: +31302729729
Endnotes
1.
Houweling ST, Kleefstra N, VanBallegooie E,
Verhoeven S, Bilo HJG, Meyboom-de Jong B. Taakverschuivingen in de eerstelijns
diabeteszorg: een enquete onder ruim vierhonderd praktijkondersteuners. Huisarts & Wetenschap 2006;118-22. (s)
2. Buchan J, Calman
L. Implementing nurse prescribing. An Updated Review of
Current Practice Internationally. International Council
of Nurses, 2004. (s)
3. Department of Health. Review of
Prescribing, Supply & Administration of Medicines: final report. London: 1999. (s)
4.
Raad voor de Volksgezondheid en Zorg. Taakherschikking in de gezondheidszorg. Zoetermeer: 2002. (s)
5. An Bord Altranais and the National
Council for the Professional Development of Nursing and Midwifery. Review of Nurses and Midwives in the Prescribing and Administration
of Medicinal Products; final report.
6. Biester DJ,
Collins JB. Prescriptive authority for nurse practitioners: a strategy for
improving access to child health care. Journal of Pediatric
Nursing 1991;419-20. (s)
7. Horton R. Nurse-prescribing in the
8. Nilsson M. Opposition to nurse-prescribing
in
9. Nuzzo JLJ. Independent Prescribing Authority of Advanced Practice Nurses.
Food and drug law journal : official journal of The
Food and Drug Law Institute 1998;35-46. (s)
10. Ganguli P. NEWS
- Clinical Nurse prescribing will cut errors. Nursing Times 2002;6. (s)
11. Harris J, Taylor J, Mackie C. Research
literature review on prescribing.
12. Latter S, Courtenay M. Effectiveness of
nurse prescribing: a review of the literature. Journal of Clinical Nursing 2004;26-32. (s)
13. Ryan T, Cash K, Hannis
D. Nurse prescribing and in-patient alcohol detoxification. Journal of
Substance Use 1999;133-41. (s)
14. Mayhew A. EPOC: The Data Collection
Checklist.
15. Higgins JPT, Green S, editors. Cochrane
Handbook for Systematic Reviews of Interventions 4.2.5 [updated May 2005]. In In: The Cochrane Library .
16. Clarke M, Oxman
AD, editors. Cochrane Reviewer's Handbook 4.1.6. In The Cochrane Library. The Cochrane Collaboration,
17. Einhorn RF, Trias M. Differences between physicians and nurses in
providing family planning services: findings from a
18.
Houweling ST, Kleefstra N, Groenier KH, Meyboom-de Jong B, Bilo HJG. De praktijkondersteuner
als hoofdbehandelaar bij patienten met diabetes
mellitus type 2 in de eerste lijn: een gerandomiseerd onderzoek. In: Houweling ST, ed. Taakdelegatie in de eerste- en tweedelijns
diabeteszorg: resultaten van de DISCOURSE-studies. Groningen: Rijksuniversiteit Groningen, 2005;49-68. (s)
19.
Houweling ST, Kleefstra N, Groenier KH, Meyboom-de Jong B, Bilo HJG. De
diabetesverpleegkundige als hoofdbehandelaar bij patienten
met diabetes mellitus type 2 in de tweede lijn: een gerandomiseerd onderzoek.
In: Houweling ST, ed. Taakdelegatie in de eerste- en
tweedelijns diabeteszorg: resultaten van de DISCOURSE studies. Groningen: Rijksuniversiteit Groningen, 2005;69-86. (s)
20.
Houweling ST, Kleefstra N, Groenier KH, Meyboom-de Jong B, Bilo HJG. De
diabetesverpleegkundige als hoofdbehandelaar bij patienten
met diabetes mellitus type 2 in de tweede lijn: de inspanningen en de kosten.
In: Houweling ST, ed. Taakdelegatie in de eerste- en
tweedelijns diabeteszorg: resultaten van de DISCOURSE studies.
21. Shum C, Humphreys A, Wheeler D, Cochrane
MA, Skoda S, Clement S. Nurse management of patients with minor illnesses in
general practice: multicentre, randomised controlled trial. BMJ 2000;1038-43.
(s)
22. Spitzer WO, Sackett
DL, Sibley JC, Roberts RS, Gent M, Kergin DJ,
23. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost
effectiveness of general practitioners and nurse practitioners in primary care.
BMJ 2000;1048-53. (s)
24. Kinnersley P,
Anderson E, Parry K, Clement J, Archard L, Turton P, Stainthorpe A, Fraser
A, Butler CC, Rogers C. Randomised controlled trial of
nurse practitioner versus general practitioner care for patients requesting
"same day" consultations in primary care. BMJ 2000;1043-8.
(s)
25. Batey MV,
26. Ferguson B, Luker
K, Smith K, Austin L, Hogg C. Preliminary findings from an economic analysis of
nurse prescribing. Int.J.Pharm.Pract. 1998;3-132. (s)
27. Hooker RS, Cipher DJ. Physician assistant
and nurse practitioner prescribing: 1997-2002. J.Rural.Health
2005;355-60. (s)
28. Luker K, Austin
L, Hogg C, Ferguson B, Smith K. Patients' views of nurse prescribing. Nursing
Times 1997;51-4. (s)
29. Luker KA, Austin
L, Hogg C, Ferguson B, Smith K. Nurse-patient relationships: the context of
nurse prescribing. Journal of Advanced Nursing 1998;235-42.
(s)
30. Roumie CL, Halasa NB, Edwards KM, Zhu Y, Dittus
RS, Griffin MR. Differences in antibiotic prescribing among physicians,
residents, and nonphysician clinicians. American
Journal of Medicine 2005;641-8. (s)
31. Pritchard A, Kendrick D. Practice nurse
and health visitor management of acute minor illness in a general practice. Journal
of Advanced Nursing 2001;556-62. (s)
32.
33. Cox C, Jones M. An evaluation of the
management of patients with sore throats by practice nurses and GPs. British
Journal of General Practice 2000;872-6. (s)
34. Ladd E. The use of antibiotics for viral
upper respiratory tract infections: an analysis of nurse practitioner and
physician prescribing practices in ambulatory care, 1997-2001. Journal of the
35. Feldman S, Bachman J, Cuffel
B, Friesen B, McCabe J. Advanced practice psychiatric nurses as a treatment
resource: survey and analysis. Adm Policy Ment.Health 2003;479-92. (s)
36. Fisher SE, Vaughan-Cole B. Similarities
and differences in clients treated and in medications prescribed by APRNs and psychiatrists in a CMHC. Archives of Psychiatric
Nursing 2003;101-7. (s)
37. Jacobs JT. Treatment of depressive
disorders in split versus integrated therapy and comparisons of prescriptive
practices of psychiatrists and advanced practice registered nurses. Archives of
Psychiatric Nursing 2005;256-63. (s)
38. James J. Supplementary
prescribing by a diabetes specialist nurse on a hospital ward. NursePrescribing 2004;112-6. (s)
39. Mallett J,
Guerrero D, Rhys-Evans F, Faithfull S. Nurse
prescribing by protocol - Nurse-run clinics ensure patients get their pills on
time. Nursing Times 1997;50-3. (s)
40. Horrocks S,
Anderson E, Salisbury C. Systematic review of whether nurse practitioners
working in primary care can provide equivalent care to doctors. BMJ 2002;819-23. (s)
41. Latter S, Maben J, Myall
M, Courtenay M, Young A, Dunn N. An evaluation of Extended
Formulary Independent Nurse Prescribing; Executive Summary of Final Report.
Department of Health,
42. Mahoney DF. Appropriateness
of geriatric prescribing decisions made by nurse practitioners and physicians.
Image J.Nurs.Sch
1994;41-6. (s)
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