Nurse prescribing of medicines in Western European and Anglo-Saxon countries: A survey on forces, conditions and jurisdictional control

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Abstract

Background

The number of Western European and Anglo-Saxon countries where nurses are legally allowed to prescribe medicines is growing. As the prescribing of medicines has traditionally been the task of the medical profession, nurse prescribing is changing the relationship between the medical and nursing professions.

Objectives

To gain more insight into the forces that led to the introduction of nurse prescribing of medicines in Western European and Anglo-Saxon countries, as well as into the legal, educational and organizational conditions under which nurses prescribe in these countries. Moreover, this study sought to determine which consequences nurse prescribing has for the division of jurisdictional control over prescribing between the nursing and medical professions.

Design

International survey.

Participants

An email survey was sent to 60 stakeholders of professional nursing or medical associations or government bodies, at national, state or provincial level across ten Western European and Anglo-Saxon countries, namely Australia, Canada, Finland, Ireland, the Netherlands, New Zealand, Spain, Sweden, the United Kingdom and the United States of America.

Methods

The survey addressed the reasons for the introduction of nurse prescribing and the conditions under which nurses are or will be prescribing medicines.

Results

The response rate was 65% (n = 39). It was shown that a diversity of forces led to the introduction of nurse prescribing, and respondents from nursing and medical associations and government bodies cited different forces as being important for the introduction of nurse prescribing. Representatives of nurses’ associations oftentimes emphasized the medication needs of patients living in remote geographical areas, while representatives of medical associations more often pointed to workforce shortages within the health care service. The conditions under which nurses prescribe medicines vary considerably, from countries where nurses prescribe independently to countries in which prescribing by nurses is only allowed under strict conditions and the supervision of physicians.

Conclusions

Citing different forces as being important in the introduction of nurse prescribing can be conceived as a professional ‘problem construction’ in order to gain jurisdiction over the prescribing task. In most countries, nurses prescribe in a subordinate position and the jurisdiction over prescribing remains predominantly with the medical profession.

Introduction

Nurse prescribing is a highly relevant issue in the current climate of cost containment and task substitution in health care. During the past decades, the number of countries where nurses are legally permitted to prescribe medication has grown considerably (Aarts and Koppel, 2009, Drennan et al., 2009). However, even though the term ‘nurse prescribing’ suffices as a descriptor term (Jones, 2009), the actual practice it refers to varies considerably, both within countries and internationally (Buchan and Calman, 2004, Kroezen et al., 2011). As a further growth of nurse prescribing can be anticipated, it is important to have a complete picture of nurse prescribing internationally, so as to inform future developments in this area.

Two crucial aspects in the organization of nurse prescribing are legislation and education (Jones, 1999), since these aspects determine who can prescribe and what can be prescribed. How legal and educational conditions translate into practice, is largely determined by the organizational conditions in place. Therefore, in describing nurse prescribing across Western European and Anglo-Saxon countries, this study focuses on the legal, educational and organizational conditions under which nurses prescribe.

Section snippets

Nurse prescribing models

Despite the variety in nurse prescribing practices found internationally (Buchan and Calman, 2004, Jones, 2009, Kroezen et al., 2011), three general models of nurse prescribing are usually distinguished in the literature. These prescribing models are useful in structuring the variety of legal, educational and organizational conditions under which nurses are prescribing internationally. Moreover, these models were used to structure our survey.

The two models most often discussed in the literature

Theoretical background

Traditionally, the task of prescribing medicines has been the sole domain of the medical profession (Buckley et al., 2006, Fisher, 2010, Goundrey-Smith, 2008). With the development of nurse prescribing, doctors are confronted with a ‘rival’ profession in this domain. This has consequences for the relationship between the medical and nursing profession, in which for example a perceived change in power balance can occur (Patel et al., 2009). After all, the introduction of nurse prescribing

Aim and research questions

The aim of this study was to gain more insight into the forces that have led to the introduction of nurse prescribing and into the legal, educational and organizational conditions under which nurse prescribing of medicines is realized in Western European and Anglo-Saxon countries. Moreover, we aimed to investigate which consequences nurse prescribing has for the division of jurisdictional control between the nursing and medical professions. The following research questions were addressed:

  • 1.

    As a

Sample

To answer our research questions, an email questionnaire was sent to representatives of national and regional professional nursing and medical associations and government representatives in ten Western European and Anglo-Saxon countries: Australia, Canada, Finland, Ireland, the Netherlands, New Zealand, Spain, Sweden, the United Kingdom and the United States of America. These countries were selected because they had realized or initiated nurse prescribing, as had been revealed in our earlier

Demographics

Of the 60 questionnaires that were mailed out, 39 were returned, yielding a response rate of 65%. This is a relatively high response rate for a survey (Ray, 1999), and may reflect respondents’ engagement in the subject. For every country, state and province, at least one survey was returned by a representative of one of the associations contacted. The response rates per country and type of organization are presented in Table 1.

Even though our general response rate was relatively high, medical

Discussion

In almost all countries involved in this study, (specific categories of) nurses are or will be allowed to prescribe on an independent basis, with the exception of three American states where nurses are only allowed to prescribe under the supervision of a physician. This form of prescribing is known as supplementary prescribing and can be found in a number of other countries as well, albeit in addition to independent prescribing. In the UK, a third main form of prescribing was distinguished,

Limitations

The study has several limitations. First, the response rate for representatives of medical associations is lower (35%) than that for government bodies (75%) and nursing associations (85%). Second, a small number of questions concerning the financial organization of nurse prescribing generated conflicting answers from respondents in the same country, state or province. This limits the degree of certainty with which we can make statements about financial aspects of nurse prescribing

Conclusion

A diversity of external and internal forces led to the introduction of nurse prescribing internationally. Respondents from nurses associations, medical associations and government bodies cited different forces as being important for the introduction of nurse prescribing. This can be conceived as professional problem construction in order to gain jurisdiction over the prescribing task. The legal, educational and organizational conditions under which nurses prescribe medicines vary considerably

Acknowledgments

The authors wish to thank Aart Eliens (V&VN – Dutch Nurses Association) and Diederik van Meersbergen (KNMG – Royal Dutch Medical Association) for their comments on the draft survey. Furthermore, our gratitude goes to all representatives and associations that participated in our survey: Christine Andrews, Ministry of Health, New Zealand; Lisa Ashley, Canadian Nurses Association; Fran Beall, Georgia Nurses Association; Jenny Beutel, Nursing & Midwifery Office, South Australia Department of

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