Metasynthesis

Systematic review utilises transparent, structured processes to review literature and this approach is equally important when reviewing qualitative literature as it requires the identification of clear criteria to support credibility, transferability, dependability and confirmability (Bearman and Dawson, Reference Bearman and Dawson2013). Metasynthesis is a systematic approach to the synthesis of findings from qualitative studies, allowing key ideas and concepts to be identified (Erwin et al., Reference Erwin, Brotherson and Summers2011) while clearly identifying the quality measures employed throughout the process. This iterative approach enables a focus on the question being asked (Downe, Reference Downe2008) and can introduce an additional layer of interpretation to those identified by the authors of the individual studies (Bearman and Dawson, Reference Bearman and Dawson2013).

Literature search

The literature search was undertaken in April 2015 (20–24), using a range of databases and resources selected because of their relevance to the subject area (Table 1). In order to gather an insight into factors that could impact the lived experience of the nurse prescriber, a broad approach was applied to the literature search, which included qualitative and mixed-methods papers. As such, the literature search included other reviews as well as primary studies. Studies that only gathered quantitative data were excluded as it was felt that the methodologies used would not provide data with the depth necessary to be relevant to a phenomenological study. International literature was included in the search, excluding only those not available in English. As the aim was to explore the perspectives and experiences of the nurse prescriber, studies that only explored the perspectives of other prescribers (doctors, physicians, pharmacists, physiotherapists, radiographers, podiatrists/chiropodists, optometrists and dentists), other staff or patients were excluded. Relevant professional nursing groups with prescribing rights were included (independent nurse prescribers; supplementary nurse prescribers; V100; V150; and V300) but this was limited to those practicing in a community or primary care setting. Although no lateral searches were undertaken, search terms were tested using Medical Subject Headings to ensure that terms used in the final searches captured all relevant data. Inclusion and exclusion criteria are identified in Table 2. The outcome of each stage of the literature search process is recorded in Figure 1.

Figure 1

Literature search and quality assessment process.

Table 1

Databases and resources included in the literature search

Table 2

Search strategy

Qualitative analysis techniques

Walsh and Downe’s (Reference Walsh and Downe2005) qualitative analysis technique was used, which ‘attempts to integrate results from a number of different but inter-related qualitative studies’ and, as such, was seen as appropriate for analysis of the range of data yielded from this literature search. In support of this technique, an adaptation of the Template for Metasynthesis and the grading system developed by Downe et al. (Reference Downe, Simpson and Steen2009) were utilised. The first stage of Downe et al.’s (Reference Downe, Simpson and Steen2009) approach required an initial screening of the full-text papers, resulting in 15 papers being rejected as the inclusion criteria were not met, a factor not clear on initial reading of the abstracts. The quality of the remaining 50 papers was reviewed by the author and two other members of the research project supervisory team, using the Quality Assessment Tool questions shown in Table 3. This stage of the qualitative analysis process gave consideration to the clarity of the aims, appropriateness of the sample, design and methodology, as well as provided evidence that the findings were justified. The review also considered reflexivity, ethical issues and rigour. On the basis of the quality assessment, papers were graded using Downe et al.’s (Reference Downe, Simpson and Steen2009) grading system (Table 4) in which failure to meet any of the quality measures was identified as a flaw. The final grades were agreed upon by the three reviewers. In view of significant flaws evident in the papers graded D, these were excluded. Although acknowledging that the papers graded C contained some flaws that may affect credibility, transferability, dependability and/or confirmability, it was deemed that they added to the overall data and met the initial inclusion criteria. After exclusion of the 13 papers graded D, 37 remained and were included in the metasynthesis.

Table 3

Quality assessment tool (Downe et al., Reference Downe, Simpson and Steen2009)

Table 4

Grading system (Downe et al., Reference Downe, Simpson and Steen2009)

Participants in the included papers represented nurse prescribers from a range of countries: United Kingdom, United States of America, Canada, Botswana, Zimbabwe, Australia, Ireland, New Zealand and Sweden. Of the 37 papers, 23 were qualitative studies, whereas 11 used mixed methods. Qualitative data from four of the mixed-methods studies were collected using surveys or questionnaires that incorporated open questions, with the remainder also using either interviews or focus groups. Only the qualitative data from the mixed-methods papers were used for this metasynthesis; however, it is important to acknowledge that, in some of the studies, it was not always possible to clearly determine whether the themes identified by the authors were based solely on the qualitative data.

The final three papers were reviews of other studies (two literature reviews and one metasynthesis). Consistency of the findings of these three papers, with the data cited from the primary studies, was reviewed. The process used by the authors to assess the quality of the papers they included was also reviewed. The rigour of this process was used to inform the grade awarded to each of the three studies. Darvishpour et al.’s (Reference Darvishpour, Joolaee and Cheraghi2014) metasynthesis included 11 papers that met their inclusion criteria. The quality of the included papers was assessed using both the AMSTAR tool and the CASP tool, with all papers graded as either strong or moderate with both tools. Similarly, the systematic review by Bhanbhro et al. (Reference Bhanbhro, Drennan, Grant and Harris2011) used the CASP tool, and of the 23 papers identified, six were excluded following quality review, because of insufficient detail on the research design and/or methodology used. Although the scores were not stated, the detail provided in the supplementary appraisal notes were suggestive of the quality of all included papers being strong or moderate. Harris and Taylor’s (Reference Harris and Taylor2004) literature review included 44 papers that met the inclusion criteria. The quality of these was assessed using an evaluation tool devised by the authors, which included review of the evidence typologies used. Again, the detail provided in the evaluation matrix aligned the quality of all included papers to grades of strong or moderate. The characteristics of the 37 studies are identified in Table 5.

Table 5

Characteristics of papers included in metasynthesis

Walsh and Downe (Reference Walsh and Downe2006) identify a three-step approach to metasynthesis, which begins by identifying relationships or differences in the studies by comparing and contrasting the data. The next stage, reciprocal translation, attempts to translate the findings of one study into another by identifying concepts that could apply to both studies. Walsh and Downe’s (Reference Walsh and Downe2006) final stage is that of synthesis of translation, where the reciprocal translations are synthesised to identify new concepts or develop a more enhanced meaning. This approach was used by the author and nine themes were identified from the literature (Table 6). These themes were agreed upon by two other members of the supervisory team.

Table 6

Three-step approach to metasynthesis

NMP=non-medical prescribing; CPD=continuing professional development; NP = nurse prescribers

The need to provide patient-centred care

The theme of ‘the need to provide patient-centred care’ was identified from 15 papers, two of which were literature reviews, one was a metasynthesis and three were mixed-methods studies. A benefit of nurse prescribing, which featured in many of the studies was the nurse prescriber’s ability to provide and improve patient-centred care, suggesting a need to integrate care into prescribing by using a holistic approach. The district nurse prescribers interviewed in Bowden’s (Reference Bowden2005) and Downer and Shepherd’s (Reference Downer and Shepherd2010) studies, referred to an improved or better quality of care as a positive outcome of NMP. Support for these findings was demonstrated in studies by Mahoney and Ladd (Reference Mahoney and Ladd2010) and Carey et al. (Reference Carey, Stenner and Courtenay2014) as well as by a metasynthesis by Darvishpour et al. (Reference Darvishpour, Joolaee and Cheraghi2014). A variety of factors influenced the nurse prescriber’s ability to provide patient-centred care through prescribing, including the ability to increase effectiveness through the timely delivery of complete episodes of care (Bhanbhro et al., Reference Bhanbhro, Drennan, Grant and Harris2011). The importance of timeliness was reflected by Lewis-Evans and Jester (Reference Lewis-Evans and Jester2004) and by Coull et al. (Reference Coull, Murray, Turner-Halliday and Watterson2013) in their Scottish study, specifically referring to NMPs having time to explain treatments. In addition, the ability to tailor prescribing to the needs of the patient was identified as a key enabler in studies by Hall (Reference Hall, Cantrill and Noyce2006) and Stenner and Courtenay (Reference Stenner and Courtenay2008b), with the desire to benefit the patient and to avoid harm identified as important.

The drive to provide patient-centred care through nurse prescribing activity, however, may not be without its consequences. Luker and McHugh (Reference Luker and McHugh2002), who carried out a postal survey across three UK Primary Care Trusts, found that nurse prescribers sometimes felt that patients expected more from them than they were able to offer. Similarly, the 2011 large-scale study by the Department of Health (DH), identified that NMP does not enable all nurses to meet the needs of all patients, largely because of concerns about prescribing for patients with co-morbidities; however, it would be fair to suggest that this issue is not exclusive to prescribing.

Benefits to the service

In addition to benefiting the patient, seven of the papers, including one literature review and two mixed-methods studies, indicated that prescribing has a positive impact on the service in which it is implemented. Bhanbhro et al. (Reference Bhanbhro, Drennan, Grant and Harris2011) identified a perception by nurses that their prescribing activity reduced doctors’ workloads but as a consequence, nurses’ workloads increased. Interestingly, doctors themselves did not recognise any reduction in their workload. It is worthy to note that nurse prescribers acknowledge time saved for other colleagues as a benefit, suggesting a shared responsibility for patient care and the ability (and willingness) to see benefits from a wider perspective. Davies (Reference Davies2005) also identified that prescribing could save time for doctors and for the patient themselves, but that this required them to spend more time with the patient. As a result, the extra time spent with one patient was often at the expense of the time available to other patients; however, some of the nurse prescribers in the study by Hall (Reference Hall, Cantrill and Noyce2006) offered a degree of counter-balance, suggesting that the extra time that the nurse prescriber had to spend with individual patients (compared with GPs) meant they were able to undertake a more thorough assessment, a finding shared by Lewis-Evans and Jester (Reference Lewis-Evans and Jester2004). As a consequence, they were able to fully explore the appropriate strategy and, therefore, were actually less likely to prescribe, supporting Coull et al.’s (Reference Coull, Murray, Turner-Halliday and Watterson2013) finding that NMP was perceived to result in a better use of resources and improved cost-effectiveness. Importantly, the improved access and appropriate prescribing of medicines through NMP is seen as having the potential to manage the many demands on health services and, consequently, has the potential to reduce patient dissatisfaction (Bhanbhro et al., Reference Bhanbhro, Drennan, Grant and Harris2011).

The need for knowledge

An issue featuring in 19 of the papers, including seven mixed-methods papers, a metasynthesis and a literature review, was the need for adequate knowledge by nurse prescribers. This included the need for knowledge required to initiate prescribing following a programme of education and for on-going updates and continuing professional development (CPD) opportunities (Bowden, Reference Bowden2005). The Scottish Government (2009) found that nurses who had undertaken a prescribing programme generally felt that it was fit for purpose, equipping them to make more appropriate use of their skills and to be more effective as nurses (Coull et al., Reference Coull, Murray, Turner-Halliday and Watterson2013); however, Hall (Reference Hall, Cantrill and Noyce2006) identified the desire for on-going education amongst nurse prescribers and, additionally, the desire for feedback on their prescribing practice to ensure that this remained effective. The on-going nature of learning and development is supported by Coull et al. (Reference Coull, Murray, Turner-Halliday and Watterson2013) who found that the prescribing skills of the participants in their study appeared to have increased over time. Bowskill (Reference Bowskill2009) referred to this as ‘an assimilation of knowledge’ whereby nurse prescribers continue to gather knowledge as they prescribe, a concept also identified by Stenner and Courtenay (Reference Stenner and Courtenay2008b).

Unfortunately, despite this need for knowledge and CPD, nurses prescribers had experienced difficulties in accessing it, particularly CPD arranged by the employers (Luker and McHugh, Reference Luker and McHugh2002; Harris and Taylor, Reference Harris and Taylor2004). Although acknowledging that these studies were undertaken relatively early on in the lifespan of nurse prescribing, the later study by Hall (Reference Hall, Cantrill and Noyce2006) also found this to be the case. More recently, Cousins and Donnell’s (Reference Cousins and Donnell2012) study, which focussed on job satisfaction and work-related stress in general practice, again identified a lack of access to updates and a lack of support from general practice for their CPD; however, it is noteworthy that nurses had differing perceptions of whose responsibility it was to provide CPD opportunities, with some accepting it as their own and actively seeking CPD activities, whereas others expected their employer to provide this for them (Hall, Reference Hall, Cantrill and Noyce2006). As such, the CPD accessed varied, with some seeking support from colleagues and using information from drug companies and journals to update themselves, whereas those in more specialised fields of practice accessed CPD that was more specialised (Luker and McHugh, Reference Luker and McHugh2002; Carey et al., Reference Carey, Courtenay and Burke2007; Carey et al., Reference Carey, Stenner and Courtenay2010). The reality of the situation was effectively summarised by the Scottish Government (2009) who suggested that a lack of support for CPD could compromise patient safety.

Professional accountability and boundary setting’

In 10 of the qualitative papers, four of the mixed-methods papers and in the metasynthesis paper, the theme of ‘professional accountability and boundary setting’ emerged. Nurse prescribers demonstrated accountability in a range of guises, including awareness of boundaries, competence and confidence. The perception of accountability differed depending on the prescribing situation, particularly when prescribing products (or for patients), where the risk was perceived as greater (Bowden, Reference Bowden2005). A prominent factor linked to accountability was the use of formularies and guidelines in setting boundaries and supporting the nurse’s prescribing practice. Stenner et al. (Reference Stenner, Carey and Courtenay2010a; Reference Stenner and Courtenay2010b) found that nurse prescribers were more likely than GPs to follow guidelines and used these to support their decision-making, whereas deviation from these was linked to a higher level of decision-making, acknowledging the individual’s accountability for complex decisions. Similarly, Hall (Reference Hall, Cantrill and Noyce2006) found that nurse prescribers who did deviate from guidelines and formularies tended to be more experienced nurse prescribers.

Darvishpour et al. (Reference Darvishpour, Joolaee and Cheraghi2014) identified competence as one of the key facilitators of prescribing and having clear links to professional accountability and to the need for knowledge. Maddox (Reference Maddox2011) aimed to examine factors that influenced competency in NMPs and found that even though they perceived themselves as competent, they were less sure that other health professionals were able to make that same judgement about them. The nurses in the study related their competence to their level of pharmaceutical knowledge, their skill in considering differential diagnoses and establishing a diagnosis and an ability to effectively monitor and modify the treatments prescribed.

Many studies that explored nurse prescribers’ experiences identified confidence as a key influence on their prescribing activity. Stenner and Courtenay (Reference Stenner and Courtenay2008b) reported an increased confidence in recommending medications amongst nurse prescribers, with Carey et al. (Reference Carey, Stenner and Courtenay2014) similarly reporting a general increase in confidence. Interestingly, confidence was seen as developmental (Luker and McHugh, Reference Luker and McHugh2002; Downer and Shepherd, Reference Downer and Shepherd2010), in that there was a perception of building up confidence to prescribe. In fact, lack of opportunity to build up and develop confidence was seen as a barrier to prescribing (Hall et al., Reference Hall, Cantrill and Noyce2003; Bradley et al., Reference Bradley, Hynam and Nolan2007). Completion of the prescribing programme was seen by nurse prescribers as a starting point from which confidence would grow, with many using their colleagues as a conduit for developing competence (Bradley et al., Reference Bradley, Hynam and Nolan2007). It is apparent that nurse prescribers give much consideration to their professional accountability and that they set boundaries on their prescribing practice in line with this.

Safety consciousness

Safety featured in four of the mixed-methods studies, the metasynthesis paper and in nine of the qualitative studies reviewed, with evidence of nurses adopting their prescribing practice to maintain the safety of their patients. Bradley et al. (Reference Bradley, Hynam and Nolan2007) found that nurse prescribers perceived their current prescribing practice as safer than the ‘by proxy prescribing’ practice previously used, as they were prescribing on the basis of their own assessment of the patient’s needs. Nurses were able to identify key processes and practices in prescribing as supporting safety, including accountability, accepting responsibility for keeping up to date and undertaking regular audits of their practice (Bradley et al., Reference Bradley, Hynam and Nolan2007); however, Carey et al. (Reference Carey, Stenner and Courtenay2014) identified that the increased responsibility for nurse prescribers often resulted in increased anxiety, with nurses worrying about making mistakes or being penalised for their prescribing decisions. Interestingly, although there was no evidence of any mistakes having been made, the nurse prescribers in Jones et al.’s (Reference Jones, Bennett, Lucas, Miller and Gray2007) study identified concern about making mistakes as a barrier to prescribing, suggesting that nurse prescribers perceive a blame-culture.

Factors that nurse prescribers considered as risks emerged in a number of studies and were closely linked to the desire to avoid harm. Maddox (Reference Maddox2011) identified that nurse prescribers perceived a ‘degree of risk’ with certain prescribing situations, such as prescribing outside of guidelines, prescribing high doses or off-label and prescribing high-risk medicines. Other concerns related specifically to characteristics of the patient, with some nurses feeling uncomfortable if prescribing for the very old and/or the very young (Hall et al., Reference Hall, Cantrill and Noyce2003). Both Maddox (Reference Maddox2011) and Carey et al. (Reference Carey, Stenner and Courtenay2014) identified that nurse prescribers appeared more concerned about safety when the patient had co-morbidities and were therefore considered to be at a higher risk, compounded in situations in which support for the nurse prescriber was not readily available. It is evident from the literature that a range of strategies are used by nurse prescribers to maintain the safety of their patients. A personal formulary was often used to support safe prescribing as it was exclusively made up of drugs that the nurse felt she/he was competent and safe to prescribe but with the decision made not to prescribe when there were safety concerns (Maddox, Reference Maddox2011). It would seem that nurse prescribers have a safety consciousness that influences their prescribing practice, although it is unclear whether this is as a result of prescribing or whether it is already inherent in their nursing practice.

Barriers to effective prescribing

Unsurprisingly, factors identified as supporting prescribing, featured as barriers when absent, a theme that emerged in the metasynthesis paper as well as in four of the mixed-methods studies and seven qualitative studies. A lack of pharmaceutical knowledge was acknowledged as a self-imposed factor in preventing nurse prescribers writing a prescription (Carey et al., Reference Carey, Courtenay and Burke2007; Coull et al., Reference Coull, Murray, Turner-Halliday and Watterson2013; Darvishpour et al., Reference Darvishpour, Joolaee and Cheraghi2014). As such, when training and support were perceived to be lacking or inadequate, this was seen as a further barrier (Davies, Reference Davies2005; Carey et al., Reference Carey, Stenner and Courtenay2014; Carey et al., Reference Carey, Courtenay and Burke2007; Maddox, Reference Maddox2011; Cousins and Donnell, Reference Cousins and Donnell2012; Coull et al., Reference Coull, Murray, Turner-Halliday and Watterson2013; Brodie et al., Reference Brodie, Donaldson and Watt2014). Brodie et al. (Reference Brodie, Donaldson and Watt2014) identified time and resources as barriers to prescribing, as well as the act of prescription writing itself, which Bowden (Reference Bowden2005) referred to as the ‘chore’ of writing prescriptions. This perception of prescribing as time-consuming was mirrored in the initiation and implementation of clinical management plans when using supplementary prescribing (Carey et al., Reference Carey, Courtenay and Burke2007) and in the prescribing of controlled drugs (Maddox, Reference Maddox2011). In these instances, referring the patient to the GP was seen as a quicker method of ensuring the patient received the necessary medicines.

For some, the clinical setting added to the challenge of prescribing. Hall et al. (Reference Hall, Noyce and Cantrill2006) found that the challenges of documenting the prescribing activity was exacerbated by the setting itself. Health visitors identified busy clinics as settings where prescribing was particularly difficult because of time constraints, with some nurse prescribers choosing not to reveal that they were able to prescribe. For others, the legal limitations of their prescribing rights and formulary limitations meant that they did not initiate prescribing, as they were concerned about providing a fragmented service (Davies, Reference Davies2005). Although all the barriers identified so far have emerged from data collected from studies within the United Kingdom, Klein (Reference Klein2015) reported on Clinical Nurse Specialists in Oregon, with some similar findings. Although some of the barriers, such as insurance costs, clearly reflected the US system, others, such as role restrictions and time pressures, were consistent.

It appears that the barriers to prescribing are, at least, in part, attributable to a general lack of infrastructure to support prescribing (Scottish Government, 2009). Coull et al. (Reference Coull, Murray, Turner-Halliday and Watterson2013) identified fragmented implementation of prescribing policy that resulted in variations in implementation. Two of the initial barriers to prescribing were difficulty in getting a prescription pad and a lack of agreement regarding budgetary arrangements (Hall, Reference Hall, Cantrill and Noyce2006; Hall et al., Reference Hall, Noyce and Cantrill2006; Carey et al., Reference Carey, Courtenay and Burke2007; Coull et al., Reference Coull, Murray, Turner-Halliday and Watterson2013). The lack of preparation for prescribing was reflected in the need for some nurse prescribers to build relationships with GPs to gain agreement to prescribe across practices (Hall, Reference Hall, Cantrill and Noyce2006; Carey et al., Reference Carey, Stenner and Courtenay2014) and some nurses experienced explicit objection to their prescribing (Hall, Reference Hall, Cantrill and Noyce2006; Hall et al., Reference Hall, Noyce and Cantrill2006). Interestingly, even though they were able to identify a number of benefits to the patient and to their role, a number of studies made reference to the nurse prescriber’s assertion that they undertook the role of prescriber without ‘reward’ through grade or pay (Davies, Reference Davies2005; Scottish Government, 2009; Downer and Shepherd, Reference Downer and Shepherd2010; Cousins and Donnell, Reference Cousins and Donnell2012; Darvishpour et al., Reference Darvishpour, Joolaee and Cheraghi2014). This desire for recognition by many nurse prescribers of the additional work and responsibility that nurse prescribing brings, may be associated with their perception of the nursing role itself.

Role preservation

A concept represented in a third of the studies reviewed (14 qualitative, three mixed-methods and a metasynthesis) was that of ‘role’, with a desire to preserve the nursing aspect of this. Prescribing was seen as an essential component of the nurses’ role, particularly for specialist nurses (Bowskill, Reference Bowskill2009; Carey et al., Reference Carey, Stenner and Courtenay2014). The nurse prescribers in Maddox’s (Reference Maddox2011) study stated they would not prescribe if they did not feel that it was within their role, yet the perception of how prescribing was accommodated within a nursing role varied. Bradley and Nolan’s (Reference Bradley and Nolan2007) study produced some rich data in relation to this issue, with some nurses feeling it legitimised their role by enabling them to ‘integrate caring and curing’, a perspective mirrored by Mahoney and Ladd (Reference Mahoney and Ladd2010) who identified that nurses felt they were ‘more than a prescriber’; however, some nurses did make a distinction between prescribing and nursing, using terms such as ‘spending more time on prescribing than nursing’ and ‘wearing lots of different hats’, demonstrating that some nurses did not see it as integral to their nursing role (Bradley and Nolan, Reference Bradley and Nolan2007). What appears to emerge from many studies is that there is a desire to differentiate the role of the nurse prescriber from that of the doctor.

‘Medicalisation’ of the nursing role was identified as a concern by nurses in a number of studies (Bradley and Nolan, Reference Bradley and Nolan2007; Scottish Government, 2009; Coull et al., Reference Coull, Murray, Turner-Halliday and Watterson2013), with a clear resistance to the suggestion that prescribing leads to medicalisation (Davies, Reference Davies2005; Bowskill, Reference Bowskill2009; Stenner et al., Reference Stenner and Courtenay2010a; Reference Stenner and Courtenay2010b). Brodie et al. (Reference Brodie, Donaldson and Watt2014) identified that in view of prescribing moving from an activity once exclusive to doctors, there had to be a necessary shift in power to enable this, reflecting what Carey et al. (Reference Carey, Stenner and Courtenay2010) termed ‘shared territory’. Indeed, prescribing was found to bring with it more job control and enhanced status (Cousins and Donnell, Reference Cousins and Donnell2012), suggesting a strengthening of the professional role of nurses through increased status and trustworthiness (Wilhelmsson and Foldevi, Reference Wilhelmsson and Foldevi2003), increased recognition and respect (Scottish Government, 2009; Coull et al., Reference Coull, Murray, Turner-Halliday and Watterson2013; Darvishpour et al., Reference Darvishpour, Joolaee and Cheraghi2014) and an ‘increased credibility and confidence to recommend medicines’ (Stenner and Courtenay, Reference Stenner and Courtenay2008b).

Power-shifts and inter-professional relationships

Of the papers reviewed, 17 that included five mixed-method papers, a metasynthesis and 11 qualitative studies presented data that were representative of the theme of ‘power-shifts and inter-professional relationships’, identifying a need for adjustments in professional relationships in order to enable effective implementation of prescribing. Bowden (Reference Bowden2005) found that nurse prescribers experienced inappropriate expectations from other health-care professionals, indicating a lack of understanding of the professional and legal boundaries of the role. Further, some prescribers experienced resistance, which some perceived as professional rivalry (Bowskill, Reference Bowskill2009). Although nurse prescribers felt support from nursing colleagues was desirable (though not essential) (Bowskill, Reference Bowskill2009) when prescribing in more complex situations in which clinical decisions were perceived to be of a higher risk, a team approach to prescribing was seen as a necessity (Lewis-Evans and Jester, Reference Lewis-Evans and Jester2004; Stenner and Courtenay, Reference Stenner, Carey and Courtenay2008a; Carey et al., Reference Carey, Stenner and Courtenay2010; Stenner et al., Reference Stenner and Courtenay2010a; Reference Stenner and Courtenay2010b).

Indeed, nurse prescribing has provided an opportunity to develop relationships with other health professionals (DH, 2011; Coull et al., Reference Coull, Murray, Turner-Halliday and Watterson2013; Darvishpour et al., Reference Darvishpour, Joolaee and Cheraghi2014), with the nurse–pharmacist relationship most frequently cited (Bowden, Reference Bowden2005; Hall, Reference Hall, Cantrill and Noyce2006; Bradley et al., Reference Bradley, Hynam and Nolan2007; Stenner and Courtenay, Reference Stenner, Carey and Courtenay2008a). Pharmacists are perceived by NMPs to have a key role in safety (Bradley et al., Reference Bradley, Hynam and Nolan2007) and are a key source of support (Klein, Reference Klein2015). Similarly, the nurse prescriber–doctor relationship was seen as important in supporting prescribing (Bradley et al., Reference Bradley, Hynam and Nolan2007; Northern Ireland Practice and Education Council for nursing and midwifery (NIPEC), Reference Nolan and Bradley2007; Bowskill, Reference Bowskill2009; Stenner et al., Reference Stenner and Courtenay2010a; Reference Stenner and Courtenay2010b). Some nurse prescribers encountered a lack of understanding by doctors of the boundaries of their role and their awareness of budgetary issues (Wilhelmsson and Foldevi, Reference Wilhelmsson and Foldevi2003; Carey et al., Reference Carey, Stenner and Courtenay2010), sometimes to the extent that they would not support nurse prescribing (NIPEC, Reference Nolan and Bradley2007). In addition, some nurse prescribers perceived that doctors considered the prescribing rights of nurses as a threat to their own profession (Bradley et al., Reference Bradley, Hynam and Nolan2007) and that prescribing should be exclusive to their profession (Wilhelmsson and Foldevi, Reference Wilhelmsson and Foldevi2003), to the extent of employing financial or managerial control on nurse prescribing without having any authority to do so (Fisher, Reference Fisher2010); however, others had a more positive experience, with doctors trusting nurse prescribers to set their own boundaries (Carey et al., Reference Carey, Courtenay and Burke2007; Bowskill, Reference Bowskill2009; Mahoney and Ladd, Reference Mahoney and Ladd2010). Prescribing was felt to have given nurses increased confidence to debate with doctors (Bradley et al., Reference Bradley, Hynam and Nolan2007) and provided more opportunity for co-operation between them (Wilhelmsson and Foldevi, Reference Wilhelmsson and Foldevi2003). Indeed, it was recognised that new boundaries of practice had to be agreed in order to work collaboratively and to enable nurses to define their prescribing role (Bowskill, Reference Bowskill2009).

Culture of prescribing

It appears that for nurse prescribing to flourish, it needs to be recognised, understood and be integral to the organisation’s processes, demonstrating a culture supportive of prescribing; a theme that emerged in six of the included qualitative studies as well as in two of the mixed-method studies and a literature review. A clear policy on NMP, access to CPD, formal support mechanisms and a learning environment that encourages knowledge sharing across professions and the opportunity to influence policy were perceived as key factors indicative of a supportive organisation (Stenner and Courtenay, Reference Stenner, Carey and Courtenay2008a). The ease with which nurse prescribing is implemented appears to be influenced by how prepared the organisation was in relation to CPD, structures and processes (Jones et al., Reference Jones, Bennett, Lucas, Miller and Gray2007; Stenner and Courtenay, Reference Stenner, Carey and Courtenay2008a; Stenner et al., Reference Stenner, Carey and Courtenay2010b). Stenner et al. (Reference Stenner, Carey and Courtenay2010b) also made reference to support structures and culture, identifying that a range of CPD mechanisms were needed to achieve structures and cultures supportive of nurse prescribing. Where good inter-professional working relationships existed, this helped to promote a supportive culture for NMP and the support of the doctor was seen as key to this; however, the large-scale study by DH (2011) found that only half of the Trusts had a strategy for the development of NMP and that it was largely driven by the practitioner to enhance existing services rather than to enable service re-design, suggesting that its benefits are not yet fully appreciated in some areas. Indeed, even when the benefits are recognised by patients, colleagues and stakeholders alike, there is still evidence of fragmentation in policy and implementation (Coull et al., Reference Coull, Murray, Turner-Halliday and Watterson2013).