Background

General practice is facing significant challenges both in the UK and internationally with increased work load causing stress and burn out amongst younger doctors whilst increasing numbers of older, more experienced doctors plan to leave the work force (Gunja et al., Reference Gunja, Gumas, Williams, Doty, Shah and Fields2022). This is on the background of a global shortage of doctors (Lawson, Reference Lawson2023). Declining general practitioner (GP) numbers in the UK have necessitated a move towards a multidisciplinary general practice-based workforce in which the development of general practice nursing is recognized as a key contributor (Royal College of General Practitioners, 2022; NHS England, 2023).

Nurse independent prescribing in the UK has developed considerably over the years since its inception in 1992 and appropriately trained nurses can now prescribe any drug for any medical condition with the exception of some controlled drugs for the treatment of addiction (National Institute of Health and Care Excellence, 2025). UK general practice nurses have increasingly taken on roles traditionally undertaken by the medical profession such as diagnosis and prescribing and are facing increasingly complex clinical decision-making in a society where multi-morbidity, and consequently polypharmacy, are common in adults over the age of 65 (National Institute for Health Care and Excellence, 2015). Historically, general practice nurses have evolved into these roles from more traditional nursing roles typified by wound care, immunizations, and chronic disease management. Such roles have been characterized by NHS England in their framework for general practice nursing which differentiates between nurses working at enhanced and advanced levels (Health Education England, 2021). A defining feature of advanced level nurses in this document is being skilled in the assessment and management of patients presenting with undiagnosed and undifferentiated conditions and having a masters’ level qualification, whilst the descriptor of enhanced level nurses is more reflective of those who have specialist knowledge in chronic disease management. Importantly an overlap between the two roles is recognized where some nurses at the enhanced level may develop ‘advanced’ clinical aspects of their role, and this is representative of many nursing roles that have developed over time in general practice (Health Education England, 2021). The framework suggests several nursing roles appropriate to each level and aligns the role of ‘nurse practitioner’ to enhanced level nurses and ‘advanced nurse’ to advanced level nurses. However, both in the UK and internationally there is confusion regarding titles given to nursing roles and their associated scope of practice and training (Leary et al., Reference Leary, Maclaine, Trevall, Radford and Punshon2017). Additionally, the titles ‘nurse practitioner’ and ‘advanced nurse practitioner’ are unprotected by law in the UK, unlike other countries such as Australia and Canada where the title nurse practitioner is protected. Consequently, these titles are used to represent a variety of roles and associated scopes of practice in the UK (Leary et al., Reference Leary, Maclaine, Trevall, Radford and Punshon2017)

Although there are moves by the NMC to regulate advanced practice (Nursing and Midwifery Council, 2025a) and a number of capability frameworks published (Health Education England, 2021; NHS England, 2025b), to date there has been no mandated training for enhanced or advanced practice. Therefore the only common post-registration training requirement for nurse prescribers in enhanced and advanced roles is a prescribing qualification, and whilst appropriate assessment and diagnostic skills are a pre-requisite to enrolment on the prescribing programme, the required level of training in these skills is not specified (Nursing and Midwifery Council, 2024b). Consequently, these nurses who are usually considered expert in general practice nursing, may be novices when taking on the more advanced aspects of these roles, specifically the complex decision-making associated with diagnosis and prescribing (Brook and Rushforth, Reference Brook and Rushforth2011).

Dual process theory, has been widely applied to clinical decision-making and recognizes that a combination of both analytical and intuitive processes is used to solve problems and make medical diagnoses (Croskerry et al., Reference Croskerry, Cosby, Graber and Singh2017). Dual process theory identifies cognitive processes that are quick, automatic, and intuitive such as pattern recognition, and those which are slow and analytical (Evans, Reference Evans2008). Croskerry (Reference Croskerry2009b) developed a model of diagnostic reasoning which exemplifies the interchange of intuitive (System 1) and analytical (System 2) processes in diagnostic reasoning and highlights the potential strengths and weakness of both systems and the risks associated with the use of intuitive processes. Intuitive processes rely heavily on the individual’s experience and utilize heuristics or mental short cuts making them efficient when applied by experts but prone to error, which may have catastrophic implications for patients (Croskerry, Reference Croskerry2009c). Intuitive reasoning, with little reliance on analytical processes, is associated with expert practice in nursing (Benner, Reference Benner1984) however, a reliance on intuitive processes informed by nursing experience to inform diagnostic and prescribing decisions in situations of complexity may be inappropriate.

Studies investigating nurse practitioners’ decision-making without a focus on multimorbidity and across a range of settings, found that both analytical and intuitive processes were used (Offredy, Reference Offredy1998; Offredy et al., Reference Offredy, Kendall and Goodman2008) with some studies indicating that where intuitive processes were used by clinicians with insufficient experience there was a risk of inappropriate decision-making (Offredy et al., Reference Offredy, Kendall and Goodman2008; Pirret et al., Reference Pirret, Neville and La Grow2015). Whilst early studies have shown nurse prescribers to be safe and effective prescribers for patients with a range of clinical conditions (Latter et al., Reference Latter, Blenkinsop, Smith, Chapman, Tinelli, Gerard, Little, Celine, Granby, Nicholls and Dorer2010; Naughton et al., Reference Naughton, Drennan, Hyde, Allen, O’Boyle, Felle and Butler2013; Weeks et al., Reference Weeks, George, Maclure and Stewart2016), there is some suggestion from some studies without a focus on patients with multimorbidity, that prescribing for this group of patients is challenging for these nurses and may not always be appropriate (Naughton et al., Reference Naughton, Drennan, Hyde, Allen, O’Boyle, Felle and Butler2013; Maddox et al., Reference Maddox, Halsall, Hall and Tully2016; Williams et al., Reference Williams, Halls, Tonkin-Crine, Moore, Latter, Little, Eyles, Postle and Leydon2017; Abuzour et al., Reference Abuzour, Lewis and Tully2018). Despite this, there are limited studies investigating the decision-making processes of nurse prescribers, and to our knowledge none that focus on nurse prescribers in general practice managing acute presentations in patients with multimorbidity. Lack of research into this increasingly important area of nurse prescribers’ practice makes investigating their decision-making processes, of prime importance

Aim

The aim of this study was to investigate the decision-making processes of nurse prescribers in general practice when managing acute episode of illness in patients with multimorbidity and explore how nurses justify and explain their decision-making.

Recruitment of participants

Fourteen general practice nurse prescribers who regularly managed acute illness presentations in adults with multi-morbidities in general practice were recruited from GP practices in the south of England. Potential participants were contacted via email through the practice manager of over 180 individual GP practices in nine clinical commissioning groups. Recruitment continued until data saturation was achieved.

Data collection

Three methods were used for data collection; think aloud in response to four vignettes and semi-structured interviews. A novel use of vignettes was piloted and used in this study. Vignettes were designed to capture the range of clinical information that might be sought by participants to support their decision-making during the course of the consultation. Review of the literature revealed that in other studies using think aloud and vignettes to investigate decision-making of nurse prescribers, the vignettes had very little requirement for participants to request information and participants were usually presented with a complete scenario at the outset (Pirret et al., Reference Pirret, Neville and La Grow2015; Abuzour et al., Reference Abuzour, Lewis and Tully2018). The acquisition of information to support decision-making in patients with multimorbidity and polypharmacy is an important element of the consultation, and by supplying a complete vignette without a requirement for participants to request this information, decision-making processes could not be comprehensively explored, and there was a risk of this vital component being overlooked.

Four vignettes representing typical examples of acute presentations to general practice in patients with multimorbidity and polypharmacy were composed by AH, an experienced advanced nurse practitioner (ANP) in primary care (See Appendix 1 for summary of vignettes). The format of each vignette was based on a clinical consultation which was divided into stages to represent the acquisition of information within a consultation Information relevant to each stage was represented on separate cards e.g. physical examination, social history, observations. By staging the consultation in this way participants were required to determine the information they needed to undertake the assessment (see Appendix 2 for example vignette). The vignettes were reviewed by two experienced clinicians for face and content validity and the process of think aloud and interviews was piloted with two experienced advanced nurse practitioners. Minor amendments were made in response to their feedback.

Data collection took place between May 2019 and February 2020. The think aloud and semi-structured interviews were conducted at a place of the participants’ choice ensuring that there was access to resources such as drug formularies that would normally be available. Semi-structured interviews took place immediately after the think aloud stage and focused on reflections on decisions prompted by the vignettes as well as participants’ typical decision-making with patients presenting with acute presentations on a background of multi-morbidity and polypharmacy in practice (see Appendix 3 for interview schedule). Interviews lasted between one to two hours and were conducted by author, AH. Interviews were audio recorded, and all data were anonymized.

Data analysis

Data analysis was informed by Braun and Clarke’s (Reference Braun and Clarke2006) framework of thematic analysis which was applied to both think aloud and interview data. Interviews were transcribed verbatim. Line by line coding was undertaken (by AH) for the think aloud and interview data for each participant.

Coding of think aloud data included pictorial representation of the information collected and the judgements and decisions made by each participant for each vignette. This enabled comparison of the structure and content of consultations between and within participants’ consultations, and judgements to be made regarding the decision-making processes utilized. In addition, each participant’s response was analysed to see to what extent they addressed the key clinical issues embedded in each vignette and the outcomes of diagnostic and prescribing decision-making were compared to what was considered to be the optimal response for each vignette. These were determined through face and content validity review of the vignettes and during the pilot process.

Codes from analysis of think aloud were considered alongside those generated from the semi-structured interviews in order to confirm or develop initial codes. Emerging and evolving themes were discussed with authors SL and CM to develop sub-themes and four over-arching themes.

Rigour and reflexivity

Rigour was maintained with reference to Lincoln and Guba’s (Reference Lincoln and Guba1985) evaluative criteria throughout to ensure the maintenance of trustworthiness. It was acknowledged that whilst author AH’s clinical background may provide valuable insights into the research area and facilitate interpretation of the participants’ experiences there was a risk of researcher bias. This occurs where the researcher’s pre-existing beliefs are not challenged, and there is a failure to look beyond their own experience (Dodgson, Reference Dodgson2019). To ensure codes were generated from the data and driven by the language used by participants, and to protect against any preconceived ideas from the author’s background, memos were made during analysis of the data and a reflexive diary maintained throughout the process (Lincoln and Guba, Reference Lincoln and Guba1985).

Findings

Participants

Fourteen nurse prescribers were recruited. All were female and had considerable nursing experience with the majority qualified for over twenty years. Most participants described themselves as ‘nurse practitioners’ whilst others used the term ‘advanced nurse practitioner’; this did not necessarily correspond to associated qualifications or the scope of the role. Details of clinical experience and qualifications are shown in Table 1. There was no single common trajectory to the advanced nurse practitioner/nurse practitioner role. For some the transition had evolved through working as a practice nurse and for others it was a new primary care role, for which they drew on previous experience from other settings. There was no uniformity to their qualifications, but most had undertaken some additional training to support their role.

Table 1. Summary of participant characteristics

* Includes university modules: history taking and physical assessment, diagnostic decision making, research methods, minor illness, transition to advanced practice.

Clinical appropriateness of responses to the vignettes

Most participants reached the anticipated diagnosis of each vignette independently, however there was considerable variation in the differential diagnoses generated in the diagnostic process and in participants’ consideration of diagnoses indicating serious disease or ‘must not miss’ diagnoses.

Overall prescribing decisions were clinically appropriate, but there was a high rate of referral to the GP for some vignettes (Table 2). Some participants chose alternatives to first line choices recommended by prescribing guidelines but mostly these prescribing decisions were justifiable. A minority of decisions would have presented a potential risk to the patient; for example, the decision by one participant to prescribe ibuprofen for a patient on warfarin.

Table 2. Participant independence in prescribing decision-making

* Data from Participant 1 in response to Vignette 1 was used as pilot data and therefore was not included in the main study.

Issues of complexity such as medication adherence and management of co-morbidities were inconsistently addressed by participants (Table 3) and consequently the impact of these on prescribing decision-making was overlooked.

Table 3. Complex factors identified by participants

* Data from Participant 1 in response to Vignette 1 was used as pilot data and therefore was not included in the main study.

Four overarching themes were established through analysis of think aloud and interview data. These were as follows: scope and content of consultations, diagnostic decision-making processes, prescribing decision-making processes, and influences on decision-making.

Implications for practice

Matching clinician skill to the patient’s problem has been shown to be of key importance in creating additional capacity in general practice (McDermott et al., Reference McDermott, Spooner, Goff, Gibson, Dalgarno, Francetic, Hann, Hodgson, McBride, Checkland and Sutton2022). Pockets of expertise based on previous clinical experience were identified amongst the participants in our study. Directing this expertise to appropriate patients could improve efficiency and patient safety. The working practices of most study participants determined that they worked independently from an individual patient list, but this was not always efficient, resulting in referral to the GP for some complex situations. With declining GP numbers and rising patient demand, findings from this study indicate that this traditional way of working might be reviewed. A minority of participants in this study described a team-based approach to the patient list which enabled flexibility in consultation times, appropriate allocation of skills, and encouraged mentorship and support from GPs. For complex patients, a team-based approach might also enable greater continuity of care with a practitioner known to them, which is shown to improve clinical outcomes and reduce consultation time (Damarell et al., Reference Damarell, Morgan and Tieman2020). However, this is clearly challenging to achieve with the current workforce crisis and in response to this some UK general practices have adopted micro-teams, an approach common in US models of care, that allocate several members of the multi-disciplinary team led by a named GP to a patient group (Baird et al., Baird, Reference Baird, Chauhan, Boyle, Heller and Price2020; Coombs et al., Reference Coombs, Cohen, Duddy, Mahtani, Owen, Roberts, Saini, Staddon-Foster and Park2023). This approach is in line with the NHS Long Term Workforce Plan (2023) (NHS England, 2023) which recognizes the need to support and develop multidisciplinary teams to manage complexity. Such teams may help to overcome both the discontinuity in patient care and the potential time burden for patients if nurses are unable to deal with their presenting condition and need to refer on to a GP. Micro-teams may be operationalized in general practices by connecting the patient with the team member with the most appropriate skills and ensuring that if the patient reconsults that the team member who knows them best and has the most appropriate skills is allocated (General Medical Council, 2025).

Time-limited appointments identified by study participants reduced the opportunity for them to seek support and develop their practice. Yet, the importance of clinical support from colleagues in developing prescribing practice is well documented in the literature (McIntosh et al., Reference McIntosh, Stewart, Forbes-McKay, McCaig and Cunningham2016; Djerbib, Reference Djerbib2018; Evans et al., Reference Evans, Pearce, Greaves and Blake2020). Development of expertise is only achieved if there is the opportunity to develop knowledge through appropriate feedback (Croskerry et al., Reference Croskerry, Cosby, Graber and Singh2017) and therefore support from GPs, particularly in complex decision-making, is fundamental to equip primary care nurse prescribers to manage the array of presentations they encounter. A team approach using micro-team involving GPs, nurse prescribers and other members of the multi-disciplinary team could enhance the opportunity for nurse prescribers to develop their knowledge and scope of practice and share their expertise with other clinicians whilst improving patient outcomes.

Implications for education

Internationally, advanced practice roles and associated training lack standardization and regulation (Wheeler et al., Reference Wheeler, Miller, Pulcini, Gray, Ladd and Rayens2022). Whilst NHS England have developed a multiprofessional framework for advanced practice (NHS England, 2025b) and accreditation of advanced practice programmes delivered by higher education institutes, these are not mandatory requirements, and advanced practice in the UK is currently not regulated. Whilst the NMC is in the process of considering steps to regulate advanced practice, including education and training (Nursing and Midwifery Council, 2024a) this is complex with standards not due to be published until 2027 (Nursing and Midwifery Council, 2025b). Furthermore, not all nurse prescribers in general practice are working as advanced practitioners. Mapped against the Health Education England, 2021 career and capability framework for general practice nurses (HEE, 2021) most participants in this study fall between enhanced and advanced level practice with their roles having a high clinical focus and, as such, would identify as nurse practitioners rather that advanced nurse practitioners and therefore would not be subject to regulation. Although the framework details core capabilities for different levels of practice, there is no jurisdiction in the Health Education England (2021) document regarding the appropriate continuing professional development (CPD) modules required by enhanced level nurses other than the specification that they should be aligned to the individual’s scope of practice.

Whilst pockets of expertise were identified in study participants, equally there were omissions and oversights in relation to the scope and content of the consultation. Preparation for nurse prescribers in general practice differs significantly from GP registrars who enter the role as qualified and experienced prescribers and are required to undertake an additional three-year period which is overseen by a GP trainer and includes rotation to hospital specialties and a rigorous system of examination (NHS England, 2025a). This may better equip GPs to manage multimorbidity and polypharmacy, although a systematic review (Damarell et al., Reference Damarell, Morgan and Tieman2020) indicates that they too experience clinical uncertainty and face decisional risk in the context of complexity and multimorbidity. Nevertheless, our findings suggest that more consistent exposure to a more comprehensive range of clinical conditions may be a necessary pre-requisite for nurse prescribers in General Practice undertaking the assessment and management of acute presentations in patients with multimorbidity and polypharmacy. These recommendations should be tailored to global contexts beyond the UK where, despite the fact that internationally the education and legal status of nurse prescribing differs (International Council of Nurses, 2021), nurse prescribers, regardless of their individual prescribing authority and training, will encounter increasing complexity in an ageing population with associated polypharmacy and co-morbidities(World Health Organization, 2025).

The reliance in this study on intuitive processes to identify complexity indicates that a more structured and comprehensive approach to history taking which routinely encompasses issues such as medication adherence and social history would be beneficial in managing complex presentations. History taking is an essential skill of prescribers (Royal Pharmaceutical Society, 2021) and using a logical, structured approach is key to successful diagnosis and management (Butler, Reference Butler2023). Furthermore, the risks associated with the use of intuitive processes identified in this study indicate that self-awareness and the ability to critical reflect on decision-making processes are highly valuable in addition to clinical experience, exposure, and mentorship when managing complex presentations. Although non-medical prescribing competencies demand a high level of diagnostic and prescribing decision-making there is currently no requirement to undertake a dedicated diagnostic or clinical reasoning module (Royal Pharmaceutical Society, 2021). NMC entry requirements for the prescribing programme stipulate that HEIs should confirm that applicants are at a proficient level in clinical assessment and diagnostic management (Nursing and Midwifery Council, 2024b) and whilst some Higher Education Institutions (HEI) demand completion of such modules prior to being accepted on to the programme, this is not universal. It therefore seems vital that where this is not an entry requirement, HEIs incorporate clinical reasoning into their NMP programmes.

Formalized and standardized training in assessment and diagnostic decision-making, alongside sufficient time to access mentorship and support is essential in order to ensure that nurse prescribers are sufficiently prepared to undertake comprehensive management of acute patients with multimorbidity and polypharmacy.

Strengths and limitations

As far as we are aware this is the first study to evaluate nurse practitioners’ decision-making when faced with acute presentations in complex multimorbid patients presenting to primary care. This study has shown the value of vignettes and think aloud methods in the study of the decision-making processes. A unique and novel aspect of this study was the use of staged vignettes that allowed the sequential process of participants’ decision-making to be shown and evaluated, and employing think aloud revealed the processes that were used to determine what information was collected. Of significance was the contribution of staged vignettes to the important findings of this research which showed that some participants focused their data collection on the presenting complaint and the revelation that complex aspects of the patients’ histories were not always explored, revealing a dependence on intuitive processes to identify complexity within the vignettes by some.

As the participant sample was self-selecting it is possible that only those who felt sufficiently confident in their management of this group of patients volunteered to participate and therefore the findings may not be fully representative of all nurse prescribers undertaking this role. Future studies focusing on less experienced general practice nurse prescribers are recommended to address this issue.