ORIGINAL RESEARCH

Nurse prescribing roles in acute care: an evaluative case study

Kathryn Jones, Margaret Edwards & Alison While

Accepted for publication 3 September 2010

Correspondence to K. Jones:

e-mail: kathryn.jones@london.nhs.uk

Kathryn Jones DHC RGN PGCE

Programme Director Modernising Nursing

Careers

NHS London, UK

Margaret Edwards PhD RN PGCE

Senior Lecturer

Florence Nightingale School of Nursing and

Midwifery, King’s College London, UK

Alison While PhD RGN CertEd

Professor of Community Nursing

Florence Nightingale School of Nursing and

Midwifery, King’s College London, UK

JONES K. , EDWARDS M. & WHILE A. (2011)JONES K. , EDWARDS M. & WHILE A. (2011) Nurse prescribing roles in acute

care: an evaluative case study. Journal of Advanced Nursing 67(1), 117–126.

doi: 10.1111/j.1365-2648.2010.05490.x

AbstractAim. This paper is a report of an evaluation of the implementation of nurse pre-

scribing in an acute care hospital in England.

Background. At the time of the study, evaluation of nurse prescribing had taken

place in community settings, but little was known about its impact and effectiveness

in acute care. Although nurse prescribing has permitted doctor–nurse substitution in

acute episodic care, some doctors have expressed concerns about patient safety in

relation to nurse prescribing.

Methods. A mixed methods single-case study was conducted in 2005–06, using

purposive sampling. Semi-structured interviews were carried out with 18 hospital

staff, non-participant observation of two nurses and two doctors undertaking 52

patient-prescriber consultations with 47 patients, and a questionnaire survey with

122 patients (response rate 61%: n = 74).

Results. Nurse prescribing was found to benefit patients through service delivery

improvement and using staff skills differently. Nurse prescribers and their colleagues

were positive about role and service changes and their impact on patient care. No

differences were found between the ways in which nurses and doctors performed

prescribing roles, but there was a statistically significant difference between the

medication-related information satisfaction ratings of patients who had seen a nurse

prescriber, compared to those seen by a doctor.

Conclusion. Nurses and doctors were found to provide equivalent care. Shared

vision, local champions, action learning and peer support were the enabling factors

that helped to embed the new prescribing roles within the study site.

Keywords: acute care, case study, new roles, nurses, prescribing, doctor–nurse

substitution

Introduction

Nursing work is changing to meet the needs of healthcare

systems as they adjust to the rising prevalence of chronic

disease and growing numbers of older people within new cost

constraints (WHO 2006). Escalating healthcare costs due to

new technologies, new drugs and increasing public expecta-

tions, together with population changes, are drivers to deliver

health care with improved efficiency and cost-effectiveness

(Buchan & Calman 2004). Prescribing by nurses reflects the

desire to maximize the capacity of the nursing workforce to

improve both the speed of access to and the quality of care

(Department of Health 2006) and has been implemented in a

number of countries, including Botswana, South Africa,

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Journal of Advanced Nursing � 2010 Blackwell Publishing Ltd 117

J A N JOURNAL OF ADVANCED NURSING

Sweden, Australia, New Zealand, the United States of

America (USA) and Canada (Calman & Buchan 2004). In

the USA, it is associated with advanced nurse practitioners

across 50 states, where it is reported to improve patient

outcomes, reduce healthcare costs and be well-received by

patients (Brooten et al. 2002).

Background

Prescribing by community nurses in the United Kingdom

(UK), which began in the early 1990s, has been extended to

suitably qualified nurses in all settings (Department of Health

2002). While independent prescribers assume sole responsi-

bility for the prescriptions that they write, including single

accountability for patient assessment and any clinical deci-

sions made, supplementary prescribers share responsibility

for their prescribing with an independent prescriber, most

frequently a doctor (Department of Health 2006). Latter

et al. (2005), in a national evaluation of independent nurse

prescribers (n = 246) in England, found that the majority of

nurse prescribers felt strongly that their prescribing had had a

positive impact on both patient care and patients’ access to

their medicines, and had also enabled staff to use their skills

better. Although a number of professional concerns were

initially raised about the preparation of nurse prescribers and

their competence to act (Avery & Pringle 2005, Chief

Medical Officer 2005, Connelly 2005, Crown & Miller

2005, Siriwardena 2006), a national evaluation of supple-

mentary prescribing confirmed its safety (Bissell et al. 2008).

Indeed, non-medical prescribing has been shown to improve

clinical decision-making across healthcare teams (Bradley &

Nolan 2007) and enable reassessment of roles within multi-

professional teams (Avery et al. 2007).

At the time of the study reported here, evaluation of nurse

prescribing in the UK had focused on primary care (Luker

et al. 1997, Latter & Courtenay 2004), with only two

published evaluations in acute care settings (James 2004,

Latter et al. 2005). Three studies had shown the positive

views of patients, prescribers and their colleagues about nurse

prescribing (Luker et al. 1997, James 2004, Latter et al.

2005), with only one study focusing solely on the views of

patients (Brooks et al. 2001). The majority of the studies,

both in primary and secondary care, had only reported nurse

prescribers’ views of their own prescribing roles (Rodden

2001, Luker & McHugh 2002, Lewis-Evans & Jester 2004,

While & Biggs 2004) to the neglect of other stakeholders. In

the light of the existing research there was a need for further

exploration of the nurse prescriber role, in particular an

understanding of the settings in which the nurse prescribers

worked, the differences that their new prescribing roles made

to established ways of team working, and the views of nurse

peers and healthcare colleagues across varied practice set-

tings. Further exploration of the differences in the roles of

medical and nurse prescribers was also needed to understand

better the ways in which each prescriber worked, and the

potential impact on patient outcomes, including satisfaction.

The study

Aim

The aim of the study was to evaluate the implementation of

nurse prescribing in an acute care hospital setting in England.

Design

An embedded single-case design with three units of analysis

(Yin 2003) was used (see Figure 1). The case study method

was selected so that a clear set of propositions about the

evolving phenomenon of nurse prescribing could be tested in

a new context of new roles and ways of working in acute care

(after Yin 2003). The units of analysis were chosen as

examples of where the phenomenon could be studied at an

operational level embedded within the case, and were used

both as sources of data collection and units of analysis. We

used multiple data collection methods, including semi-struc-

tured interviews, non-participant observation of patient-

prescriber consultations and a patient survey using validated

New roles and ways of working for patientbenefit with better use of staff skills

Implementation of nurseprescribing in an acute care

hospital

Renal out-patients clinic

(embedded unit ofanalysis 2)

Hypertensionclinic

(embedded unit ofanalysis 1)

Renal satelliteunit

(embedded unit ofanalysis 3)

Figure 1 The selected case.

K. Jones et al.

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118 Journal of Advanced Nursing � 2010 Blackwell Publishing Ltd

rating scales, to investigate the experiences of multiple

stakeholders in relation to the implementation of nurse

prescribing. The triangulation of data from multiple data

sources can confirm or refute the evidence found (Hutchinson

1990). The main stakeholders were patients, prescribers and

their colleagues (as recommended by Brooks et al. 2001,

Latter & Courtenay 2004, Latter et al. 2005), and other

hospital staff who held senior strategic positions. Proposi-

tions derived from practice knowledge were developed

through discussions with staff and from an analysis of policy

and professional literature, and were used to direct the study

(see Table 1). An element within the case was a quasi-

experiment to test the null hypotheses that there were

no differences between the roles of medical and nurse

prescribers.

Setting

One acute care hospital in England was selected as a case

study. The hospital was located in a densely populated

metropolitan borough with an ethnically diverse population

[in 2001, 27% of the local population were from black and

minority ethnic (BME) groups and 44% were born outside

the UK], had 630 beds and employed 3500 staff to deliver

general and specialist services. There were nine nurses who

had undertaken preparation for prescribing, of whom seven

(78%) were actively prescribing.

Participants

Three clinical departments were purposively selected as units

of analysis because the doctors and nurses were early imple-

menters of nurse prescribing and had been involved in the study

design. These were the hypertension clinic, renal clinic and

renal satellite unit. A purposive sample of staff was interviewed

(n = 18) to explore the background and intended purpose of

the new roles and the experiences of the nurse prescribers and

their teams. Staff members were selected because they were

prescribers (n = 3), mentors or colleagues (n = 7), or senior

hospital staff (n = 8) who had influenced the implementation

of new roles and ways of working within the organization,

including the Directors of Medicine, Nursing, Human

Resources and the Chief Pharmacist. The sample was not

extended further because data saturation was achieved. Two

nurses and two doctors from the hypertension and renal clinics

were purposively selected for the observed opportunistic

patient-prescriber consultations, through discussion with the

lead clinicians for each service, as being exemplars of the new

service delivery arrangements. A convenience sample of

patients (n = 122) who attended the hypertension and renal

clinics were invited to complete a questionnaire if they met the

principal inclusion criteria of understanding an oral explana-

tion of the study in English and were able to complete the

questionnaire in English. Statistical advice was sought about

the patient sample. Although the sampling strategy yielded a

Table 1 Propositions derived from prac-

tice knowledge, with links to relevant liter-

ature

Proposition Evidence for proposition

Nurses spend more time with patients

than doctors

Luker et al. (1997),

Horrocks et al. (2002),

Buchan and Calman (2004),

Latter et al. (2005),

Laurant et al. (2005)

Nurses give patients more information about

their medicines than doctors

Luker et al. (1997),

Brooks et al. (2001),

Rodden (2001)

Patients who have medicines prescribed by

nurses are more knowledgeable about their

medicines than those who have medicines

prescribed by doctors

Wilson-Barnett and Beech (1994)

Patients who have medicines prescribed by

nurses are more compliant with their

treatment than those who have medicines

prescribed by doctors

Brown and Grimes (1995),

Berry et al. (2006)

Patients who have medicines prescribed by

nurses experience fewer side effects than

those who have medicines prescribed by

doctors

Taylor et al. (1997)

Prescribing is a risky activity irrespective of

the professional background of the

prescriber

Crown and Miller (2005)

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non-probability sample, the participants were chosen because

of the likelihood that they would give information relevant to

the study aim and would be most likely to confirm or refute the

propositions held (Flyvbjerg 2001).

Data collection

Data were collected from July 2005 to September 2006 using

semi-structured interviews with staff (n = 18) (July 2005–

September 2006), structured non-participant observation of

doctors (n = 2) and nurses (n = 2) conducting patient consul-

tations (n = 52) (November 2005–January 2006), and a

patient survey (n = 122) (November 2005–April 2006). In

the semi-structured interviews we investigated both the back-

ground and intended purpose of the nurse prescribing roles and

the experiences of the prescribers and of their colleagues, and

were guided by questions formulated from the policy literature.

Nurse prescribers were each interviewed on two occasions,

once at the beginning of the study and then again 9 months

later in a follow-up interview, when their colleagues were also

interviewed. Senior staff were interviewed at the beginning of

the study. Non-participant observation and a patient survey

were used to investigate the null hypothesis. A structured

observation sheet (15 items) was devised to assess prescriber

competence (demonstrated/not demonstrated), in particular

the ability to manage the patients’ medicine needs, based on a

tool that had been used in a national evaluation (Latter et al.

2005) and an Observed Structured Clinical Examination

(King’s College London 2004) tool in frequent use. The

researcher (KJ) was an established practitioner who was

familiar with structured observation for the assessment of

clinical practice competence. Consultations were observed

with patient consent at opportunistically selected clinics. Dual

observation of consultations was not undertaken because it

would have compromised the professional consultations, and

this approach precluded an estimate of inter-rater reliability.

The patient data were collected using a structured question-

naire (40 items) which included validated rating scales to assess

respondents’ beliefs about their medicines (10 items) [Beliefs

about Medicines Questionnaire (BMQ): Horne et al. 1999]

and their satisfaction with the information they received from

the prescriber (17 items) [Satisfaction with Information about

Medicines Scale (SIMS): Horne et al. 2001].

Ethical considerations

The study was approved by the appropriate research ethics

and governance committees. Four potential ethical issues

were considered during the design and development of the

study: the relationship between the researcher and the

prescribers; a risk that the findings might suggest that nurse

prescribers were either ‘not as good as’ or ‘better at’

prescribing than medical prescribers; a risk that patient

consultations might be compromised by the presence of a

researcher; and a risk that patients might not like the service

provided. Participants in all components of the study were

given study information sheets and time to consider partic-

ipation, with the assurance for patients that their participa-

tion was entirely voluntary and would not jeopardize their

care or treatment in any way.

Data analysis

The qualitative data were analysed using Ritchie and Spencer’s

(1994) data analysis framework, which is a deductive

approach that enabled the systematic sifting, charting and

organization of the data according to key issues and themes.

Quantitative data were analysed using the Statistical Package

for Social Sciences Version 14 (SPSS Inc., Chicago, IL, USA).

Numerical data were summarized using descriptive statistics.

Non-parametric techniques were used to analyse categorical

data and those that were not normally distributed.

Validity and reliability

In accordance with recommendations for case study rigour

(Yin 2003), the study was guided by propositions. The

interview schedule was guided by a literature review to

enhance content validity, and the observation schedule was

developed from tools that had been tested and used previously

to measure the performance of nurse prescribers (King’s

College London 2004, Latter et al. 2005). The patient survey

questionnaire included items taken from validated rating

scales designed to assess patients’ attitudes to and knowledge

about their medicines (Horne et al. 1999, 2001), and general

satisfaction questions taken from a national outpatient

questionnaire (Healthcare Commission 2005) that enabled

service comparison against national norms published as part

of health service monitoring. Although the potential for

researcher bias is acknowledged, a consistent approach to the

data was adopted, including member checking (Stake 1995)

by all participants at two levels: verification of interview

transcripts and credibility of the thematic analysis and

interpretation. The approaches to data analysis and interpre-

tation were regularly checked within academic supervision.

Results

The sample comprised 18 staff who participated in the

interview: nurse prescribers (n = 3), their medical, nursing

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and pharmacy colleagues (n = 7) and senior hospital staff

(n = 8) (response rate 100%); of two nurses and two doctors

who were observed undertaking 52 patient-prescriber con-

sultations with 47 patients; and 122 patients who completed

the questionnaire (response rate 61%: n = 74; 51% white,

47% from BME groups).

Background and intended purpose of the prescribing roles

The staff who participated in interviews unanimously

reported that the overall intention of nurse prescribing was

for patient benefit and that it yielded improved timeliness of

care, better patient outcomes, improved team-working,

advancement of working, legitimization of practice and

increased patient and staff satisfaction:

Today it was great. I saw a … new patient today, and his blood

pressure was [states value] and he’d run out of his medication and it

would have taken him 48 hours at least to go back to his GP and get

more medication. He hadn’t had medication for a week. He was at

risk. I knew he had brought his tablets, I knew what he needed to

take and I was able to write him a prescription. (Nurse Prescriber 1)

Experiences of nurse prescribers and their teams

At the time of their initial interview the nurse who worked in

the hypertension clinic had been prescribing for 18 months,

while nurses from the renal clinic and renal satellite unit had

been prescribing for 11 months. All three nurse prescribers

considered that their prescribing practice had had a positive

impact on patient care and team-working, and had also

enabled them to make better use of their nursing skills:

I can’t split it up [the impact of nurse prescribing]. If I think about

how patients are sent to me here…our patients are very com-

plex...The doctors and I share caring for those patients totally, and

the way they use me is that they will see a patient and decide on the

way they are going to go with medication, which is their skill, and

then they will send the patient to me on a few occasions to titrate

medication, add medication. And they will have decided what format

to follow, and I will follow that format and I may discharge patients

from that. Because patients may come to me it allows the doctor to

see more patients that are more complex (that’s what their role is)

and I can – rather than sending them back to the GP, the patient stays

under our care, and I look after them in that format until they are

ready to go back to the GP. (Nurse Prescriber 1)

The themes identified in the data set were: increased

confidence to prescribe, improved patient care, increased

role fulfilment and successful implementation of nurse

prescribing. For example, all three nurse prescribers reported

that they felt confident prescribing, but acknowledged that

their confidence had developed with time. They all identified

doctor colleagues, nurse managers and peers as key to the

successful implementation of their prescribing role, and the

importance of existing, and supportive, team-working, to

their prescribing practice. They viewed the support of senior

nursing staff positively – specifically an action learning set

that had been established to provide support for novice nurse

prescribers:

We do have a culture of nurses extending roles [in the renal unit] so

then the support has already been there. Then it really, I think really,

was the support of the Trust – the action learning and being part of

the Trust, because it’s all very well doing it in renal but you do feel

very isolated. So it was very important to come outside of that and

have this opportunity to talk around the table. (Nurse Prescriber 3)

I decided to do it and was supported by the doctors because of their

research [trials] and getting nurses to increase drugs. They need

nurses who are good at it… they knew it was a safe thing for me to

do. (Nurse Prescriber 1)

The colleague sample also unanimously reported the benefits

of nurse prescribing to patient care, which was reflected in

improved timeliness of treatment, improved patient care,

improved team-work, influence on colleagues and changed

team workloads:

It’s been really positive. They [the patients] are not waiting around

for the doctors to sign prescriptions or for [names nurse prescriber] to

discuss [treatment] with the doctors. She’s able to do the whole

consultation and so it’s very positive for patients. (Nurse Colleague 5)

[She] sees patients in an individual fashion. She is extremely

experienced in what they need and when they need it and the

patients therefore get the drugs quicker. They don’t have to wait

around so long. (Doctor Colleague 1)

Differences in roles of medical and nurse prescribers

Findings from the observation data

Forty-seven patient-prescriber consultations were observed,

of which two-thirds (n = 30) took place in the renal clinic and

one-third (n = 17) in the hypertension clinic. Sixty per cent

(n = 28) of the consultations were between a patient and a

nurse, and 40% (n = 19) were between a patient and a doc-

tor. No differences were found in prescribers’ approaches to

their patients or in the ways in which they managed their

medicines. No statistically significant difference was found

between the length of the observed patient-prescriber con-

sultation and the profession of the prescriber (Chi-square

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test). Also, no difference was found in the prescribing practice

of the doctors and the nurses, including the number and types

of items prescribed per patient although some difference was

noted in the methods of prescription used, for example, new

or repeat medicine, but the dataset was too small to test for

statistical significance.

Findings from the survey data

Seventy-four patients returned completed questionnaires (res-

ponse rate 61%), of whom 51% (n = 38) were white and

47% (n = 35) from BME groups: Black Caribbean (n = 12);

Black African (n = 7); Asian (n = 8); Chinese (n = 4); Mixed

(n = 3); and Black other (n = 1). Seventy-two per cent

(n = 53) of the patients had attended the renal clinic and 28%

(n = 21) had attended the hypertension clinic. Three-quarters

(n = 57) had consulted a nurse and one quarter (n = 17) had

consulted a doctor, but 12 more patients reported that they

had consulted a doctor (n = 29) than had actually done so.

Patients unanimously reported confidence and trust in their

prescriber, irrespective of whom they thought that they had

consulted.

The beliefs held by patients about their prescribed med-

icines were measured using the BMQ (Horne et al. 1999).

Specific-necessity and specific-concern scores were calculated

for each of the 69 (93%) patients who had fully completed

the BMQ. In a possible range of 1–5, scores ranged from 2Æ2–

5 for specific-necessity and 1–5 for specific-concern. The

scores indicated beliefs about the necessity of medicines for

maintaining or improving health and about the potential

adverse effects of taking medicines. No statistically signif-

icant difference was found between BMQ scores and the

profession of the prescriber (Chi-square test). For example,

44% (n = 24) of patients who had consulted a nurse attained

a specific-necessity score of 5, as did 40% (n = 6) of those

who had consulted a doctor; the majority (53%, n = 8) of

those who had consulted a doctor scored 4 for specific-

necessity, as did 43% (n = 23) of those who had consulted a

nurse. These scores indicated strong beliefs in the value of

taking medicines to maintain or improve health. The

majority (74%, n = 40) of the patients who had consulted

a nurse attained a specific-concern score of 2–3, as did 73%

(n = 11) of those who had consulted a doctor. These scores

indicated low to moderate concern about the adverse effects

of taking medicines. Whilst no difference was found between

specific-necessity scores and patients’ ethnic origin, some

difference was noted relating to specific-concern scores. For

example, most patients with higher overall specific-concern

scores (indicating the greatest concerns about their medi-

cines) were from BME groups (64% n = 9), but the data set

was too small to test for statistical significance.

Patients’ satisfaction with the medication information

received from their prescribers was measured using the SIMS

(Horne et al. 2001). Total satisfaction rating scores were

calculated for each of the 64 patients (86%) who had fully

completed the SIMS tool, and were grouped by the profession

of the prescriber (Table 2). Scores ranged from 2 to 17

(possible range 0–17), with higher scores indicating a higher

degree of satisfaction. There was a statistically significant

difference between the satisfaction ratings of patients who

had seen a nurse and those who had seen a doctor, with 66%

of those (n = 33) who had consulted a nurse reporting a

satisfaction rating of 17, compared to 7% (n = 1) of those

who had consulted a doctor (v2 = 15Æ22, d.f. = 1, P <

0Æ001). Comparison of mean total satisfaction rating scores

across the professional groups was also statistically signifi-

cant, with nurses scoring a higher mean rank (36Æ56) than

doctors (18Æ0) (v2 = 12Æ82, d.f. = 1, P < 0Æ001) using the

Kruskal–Wallis test. There was also a small difference when

comparing the scores of patients from different ethnic groups;

for example, more patients from BME groups (59%, n = 20)

attained a score of 17 than white patients (41%, n = 14),

but the data set was too small to test for statistical

significance.

Discussion

Study limitations

In this small study we used a case study design in one acute

hospital as little was known about the impact and

effectiveness of nurse prescribing in the acute care setting;

therefore the findings must be considered tentative until a

larger study is conducted. Although a purposive sampling

yielded a non-probability sample, every attempt was made

to enhance validity and reliability at all stages of the

research process. The use of a single observer without inter-

Table 2 Patients’ total satisfaction rating scores grouped by pro-

fession of prescriber

Profession

Total satisfaction rating score

Total1–10 11–16 17

Nurse (n = 50) 6

(12%)

(60%)

11

(22%)

(68%)

33

(66%)

(97%)

50

(100%)

Doctor (n = 14) 4

(29%)

(40%)

9

(64%)

(32%)

1

(7%)

(3%)

14

(100%)

Total 10

(100%)

20

(100%)

34

(100%)

64

(100%)

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rater observation may be a weakness; however, there were

ethical considerations which took priority, as recommended

by the research ethics committee. The use of video-recording

is an alternative means of data collection which could have

been considered in a study where the consultation process

was the focus of enquiry. Unfortunately the dataset was

limited, with fewer observed patient-doctor (n = 19) than

patient-nurse consultations (n = 28), and fewer question-

naires from patients who had seen a doctor (n = 17) than

had seen a nurse (n = 57); however, the data were sufficient

to explore the phenomenon of interest in the context of a

case study.

Benefits of nurse prescribing

Whilst the findings add to the growing body of knowledge

about nurse prescribing, they are distinctive from others to

date because we explored nurse prescribing from an organi-

zational perspective using data from multiple levels, including

senior managers and patients from a range of ethnic groups.

Nurse prescribing was reported to be of patient benefit,

echoing the findings of others (Luker et al. 1997, Latter &

Courtenay 2004, Latter et al. 2005). Similarly, the qualitative

data themes corresponding to the drivers for non-medical

prescribing identified previously in the policy literature,

namely quicker and more efficient access to medicines for

patients and better use of staff skills (Department of Health

2002, 2006). The nurse prescribers in this study reported

competence and confidence in prescribing, and considered

that their prescribing practice had had a positive impact on

both patient care and team-working and had also enabled

them to use their nursing skills better, as found by others

(Luker et al. 1997, Latter et al. 2005, Courtenay et al. 2006,

2007a, 2007b, Bradley & Nolan 2007, Carey et al. 2007,

Courtenay & Carey 2008, Stenner & Courtenay 2008a,

2008b).

Doctors, nurse managers, peers and supportive team-

working were identified as key to the successful implemen-

tation of nurse prescribing roles as reported by others (Latter

et al. 2005, Courtenay et al. 2006, Bradley & Nolan 2007,

Stenner & Courtenay 2008a, 2008b). In this study, nurse

prescribers and their colleagues also made reference to the

‘fit’ of the new roles into existing team structures as helpful to

implementation. For example, the hypertension and renal

teams had reviewed uni-professional roles and joint ways of

working in the light of the need to manage increased

caseloads. However, it was the nurses themselves who were

considered by managers, peers and colleagues to be crucial to

the project’s success, through their motivation, enthusiasm

and drive to succeed.

In contrast to Brooks et al. (2001) and Latter et al. (2005),

we surveyed the views of patients from a variety of ethnic

groups. All reported similar views about their prescribing

experience and their medicines, irrespective of their ethnic

background. No other study to date has explored the

prescribing experience of patients from different ethnic

groups. In fact, apart from an evaluation of the impact of

prescribing by a diabetes nurse specialist (Carey et al. 2008),

no other recent studies have included patients in their

samples. This is both an omission and an opportunity for

future research, given that modern healthcare systems are

increasingly focusing on patient choice and improving the

user experience (Department of Health 2008a).

Nurses and doctors were found to deliver equivalent care,

but patients who reported the highest satisfaction ratings of

medicine-related information had seen a nurse. A systematic

review of the research into doctor-nurse substitution in

Desired stateImplementation of nurse prescribing

Workforce changes

Improved service delivery

Improved patient care

Sponsors and supportersof changed practice

Advanced personal andprofessional practice

Expert care

Team engagement

Better medicine management

Enabling factors:Shared vision

Local champions Action learning

Team, peer and buddy support

Evolving infrastructure

Emerging policy

After Lewin (1951)

Driving

forces

Current

state

Resisting

forces

Figure 2 A force field analysis for the implementation of nurse

prescribing (Strength of line indicates strength of supporting evidence

derived from the data set. Dotted lines indicate forces arising as a

result of the implementation of the new service model).

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Journal of Advanced Nursing � 2010 Blackwell Publishing Ltd 123

primary care has shown that the quality of care is similar for

patients seen by nurses as compared to those seen by doctors,

with no appreciable differences in health outcomes, although

higher satisfaction is reported by some patients (Horrocks

et al. 2002). Systematic reviews of the research literature

have also shown no appreciable differences in the care

delivered by doctors and nurses, although nurses spend

longer with patients (Horrocks et al. 2002, Buchan &

Calman 2004, Laurant et al. 2005). However, in the present

study the majority of the patients with the longest consulta-

tion times were seen by a doctor, which may partly be

explained by doctors seeing patients with more complex

morbidity and therefore needing longer consultations. Thus,

patients who reported higher satisfaction ratings had not

spent longer with their prescribers. This is an important

finding for healthcare professionals in England, where policy

directives focus on service improvements through changes in

delivery and role redesign (Department of Health 2008a,

2008b). The process of training team members to prescribe

has also been shown to enable reassessment of roles (Avery

et al. 2007) and improve clinical decision-making across

healthcare teams (Bradley & Nolan 2007).

A synthesis of the findings (after Lewin 1951) offers a

potential model of the driving and resisting forces identified

from the dataset which have an impact on implementation

of new nurse prescribing roles within a chosen site (see

Figure 2). These driving forces included viewing workforce

changes as an opportunity, improved patient care, better

medicine management, effective sponsorship and support of

change, team engagement, advanced practice and expert

care. The restraining forces were evolving infrastructure and

emerging policy. Thus, we recommend that employers

ensure that supportive and operational infrastructures are

in place to underpin new prescribing practices if a major

change is to be successfully implemented. Most importantly,

four variables were identified as actively enabling the

implementation of nurse prescribing roles: shared vision,

local championship, action learning and team, peer and

buddy support.

Conclusion

In the light of growing evidence of the competency of nurse

prescribers, it is now timely to focus less on behavioural and

affective measures of prescribing performance and more on

the impact that the role may have on enhancing the quality

and safety of patient care, such as identifying those interven-

tions that improve patient safety by reducing prescribing

errors. In this way, the benefits or otherwise of nurse

prescribing roles can be more comprehensively assessed,

using clearly defined performance indicators and patient

outcomes and findings compared with those derived from

preliminary reports on nurse prescribing in terms of ‘equiv-

alency to’ or ‘substitution for’ doctors only.

Acknowledgements

With acknowledgement to Jill Bunker, Wendy Brown and Jen

McDermott, the nurse prescribers who participated in this

study.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

What is already known about this topic

• Nurse prescribing works well in some primary care

settings.

• Nurse prescribing has permitted doctor–nurse

substitution in acute episodic care.

• Some doctors have expressed concerns about patient

safety and nurse prescribing.

What this paper adds

• Nurses and doctors provided equivalent care, but

patients who had seen a nurse reported higher

satisfaction ratings of medicine related information.

• Patients across ethnic groups reported similar views

about their prescribing experience and about their

medicines.

• Shared vision, local champions, action learning, team,

peer and buddy support were key to successful

implementation of nurse prescribing roles.

Implications for practice and/or policy

• Employers should ensure that supportive and

operational infrastructures are in place to underpin new

prescribing practices.

• Future research is needed to measure the impact that

nurse prescribing may have on improving patient

outcomes.

K. Jones et al.

� 2010 The Authors

124 Journal of Advanced Nursing � 2010 Blackwell Publishing Ltd

Author contributions

KJ was responsible for the study conception and design. KJ

performed the data collection. KJ performed the data

analysis. KJ was responsible for the drafting of the manu-

script. ME and AW made critical revisions to the paper for

important intellectual content. ME and AW provided statis-

tical expertise. ME and AW supervised the study.

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K. Jones et al.

� 2010 The Authors

126 Journal of Advanced Nursing � 2010 Blackwell Publishing Ltd