Review
The effects of nurse prescribing: A systematic review

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Abstract

Background

In 2008, we conducted a systematic review on the effects of nurse prescribing using studies with a comparative design. In view of the growing number of countries that are introducing nurse prescribing and the fact that several studies into nurse prescribing have been conducted recently, there is a need for an updated review to reassess the available information on the effects of nurse prescribing when compared to physician prescribing.

Objective

To identify, appraise and synthesise the evidence on the effects of nurse prescribing when compared to physician prescribing on the quantity and types of medication prescribed and on patient outcomes.

Data sources

In addition to the previous review, which covered the literature up to 2005, 11 literature databases and four websites were searched for relevant studies from January 2006 up to January 2012 without limitations as to language or country. Moreover, full-text copies of all studies included in the previous review were reviewed.

Review methods

A three-stage inclusion process, consisting of an initial sifting, checking full-text papers for inclusion criteria and methodological assessment, was performed independently by two reviewers. Data on effects were synthesised using narrative and tabular methods.

Results

Thirty-five studies met the inclusion criteria. All but five studies had a high risk of bias. Nurses prescribe in comparable ways to physicians. They prescribe for equal numbers of patients and prescribe comparable types and doses of medicines. Studies comparing the total amount of medication prescribed by nurses and doctors show mixed results. There appear to be few differences between nurses and physicians in patient health outcomes: clinical parameters were the same or better for treatment by nurses, perceived quality of care was similar or better and patients treated by nurses were just as satisfied or more satisfied.

Conclusions

The effects of nurse prescribing on medication and patient outcomes seem positive when compared to physician prescribing. However, conclusions must remain tentative due to methodological weaknesses in this body of research. More randomised controlled designs in the field of nurse prescribing are required for definitive conclusions about the effects of nurse prescribing.

Introduction

Nurses can legally prescribe medication in quite a number of countries nowadays, including Australia, Canada, Finland, Ireland, New Zealand, Norway, South Africa, Sweden, the Netherlands, the United Kingdom and the United States of America (Aarts and Koppel, 2009, Ball, 2009, Drennan et al., 2009, Kroezen et al., 2011, Kroezen et al., 2012, Ministry of Health WaS, 2011, Van Ruth et al., 2008). The extension of prescribing rights to nurses has been introduced for several reasons. It is expected, among others, that nurse prescribing will contribute to efficient and effective patient care and will improve the quality and continuity of care (Buchan and Calman, 2004, Department of Health, 1999, Department of Health, 2002, Dutch House of Representatives, 2011, Emmerton et al., 2005, Kroezen et al., 2011, Ministry of Health WaS, 2011, Van Ruth et al., 2008). Moreover, nurse prescribing offers the potential to make better use of nurses’ professional skills, increase nurses’ autonomy and yield time savings for medical practitioners and patients (Bradley and Nolan, 2007, Buchan and Calman, 2004, Department of Health, 1999, Kroezen et al., 2011, Raad voor, 2002).

Even though the term ‘nurse prescribing’ suffices as a descriptor, the actual practice it refers to varies considerably, both within countries and internationally (Kroezen et al., 2011, Kroezen et al., 2012, Jones, 2009). Nonetheless, three general models of nurse prescribing are usually distinguished in the literature, viz. independent prescribing, supplementary prescribing and prescribing based on patient group directions (see Box 1). This review will adhere to this general classification.

In 2008, the Netherlands Institute for Health Services Research (NIVEL) conducted a systematic literature review of the effects of nurse prescribing using studies with a comparative design (Van Ruth et al., 2008). In this review we concluded that overall, the effects of nurse prescribing appeared to be positive. However, of the 23 studies that were included in the review, all but two had a high or moderate risk of bias, based on the EPOC criteria (Cochrane Effective Practice and Organisation of Care Review Group, 2002). The present systematic review is an update of this earlier review (Van Ruth et al., 2008). Since our previous review was published, nurse prescribing has been introduced in two more countries, viz. Finland and the Netherlands (Ministry of Health WaS, 2011, Pharmaceutisch Weekblad, 2011). Moreover, quite a number of studies and evaluations from other countries have appeared. Nurse prescribing has been in place by now for a substantial number of years in some countries, such as Ireland and the UK, increasing the opportunity for more in-depth research and publications. In view of the growing number of countries that are introducing nurse prescribing and the fact that several studies into nurse prescribing have been conducted recently, there is a need for an updated review to reassess the available information on the effects of nurse prescribing.

While several reviews have been conducted into the legal and/or educational conditions under which nurse prescribing has been implemented in different countries (Banning, 2004, Kroezen et al., 2011, Ryan et al., 1999), and other non-systematic reviews have addressed the advantages of nurse prescribing in terms of access and delivery of care and nurses’ knowledge and skills (An Bord, 2005, Creedon et al., 2009, Harris et al., 2004), few reviews have examined the effects of nurse prescribing on medication and patient outcomes. These are important outcome measures though, firstly because nurse prescribing is often introduced to improve the quality of care, of which medication and patient outcomes are important measures. In the second place they are important because questions have been raised about the adequacy of nurses’ educational programmes and whether nurses have the competence to prescribe medicines (Avery and Pringle, 2005, Banning, 2004, Crown and Miller, 2005, Horton, 2002, Nilsson, 1994, Siriwardena, 2006, Wilhelmsson and Foldevi, 2003).

As said, in 2008 we conducted a systematic review of the effects of nurse prescribing on medication and patient outcomes using studies with a comparative design. Three other reviews also studied the effects of nurse prescribing, but these lacked a comparative design (Bhanbhro et al., 2011, Latter and Courtenay, 2004, O’Connell et al., 2009, Van Ruth et al., 2008). Latter and Courtenay (2004) found that nurse prescribing has generally been evaluated positively (Latter and Courtenay, 2004). However, their review lacked a systematic approach as well as a comparative design. O’Connell et al. (2009) reported advantages of nurse prescribing for both patients and nurse prescribers, but concluded that further research, preferably randomised controlled trials (RCTs), would be useful to determine the benefits of nurse prescribing versus doctor prescribing (O’Connell et al., 2009). Bhanbhro et al. (2011) conducted a systematic literature review on the contribution of prescribing in primary care by nurses, indicating that nurse prescribing effectively improves patients’ condition and provides a better level of care. However, many of the studies included in this review had design weaknesses and limitations, and only two presented comparative data about general practitioners. Hence, these reviews into the effects of nurse prescribing all lacked a comparative design to compare the effects of nurse prescribing to physician prescribing. However, a comparison with the traditional approach of prescribing by medical professionals is a necessary prerequisite in order to properly assess the value of nurse prescribing.

The aim of this updated review was to identify, appraise and synthesise the evidence presented in the literature on the effectiveness of nurse prescribing compared to physician prescribing. We looked for evidence about the effects of nurse prescribing on the quantity and types of medication and on patient outcomes. The following research questions were addressed:

  • 1.

    What are the effects of nurse prescribing on the quantity and types of medication being prescribed?

  • 2.

    What are the effects of nurse prescribing on patient outcomes?

Section snippets

Methods

A more stringent update of the systematic literature review by Van Ruth et al. (Van Ruth et al., 2008) was conducted, working in accordance with the steps in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement (Moher et al., 2009) and the Cochrane Handbook for Systematic Reviews (Higgins and Green, 2011). This update differs from the previous review in that it does not include qualitative study designs. Furthermore, in contrast to the earlier review, we do

Search and inclusion results

After duplicates had been removed, the searches in the different databases resulted in an initial set of 6588 references of potential interest. Initial sifting based on title and abstract reduced this set to 593 references. As said, a 10% sample of all references was initially studied independently by two reviewers (JD and SG), looking at the title and abstract. These reviewers had good/moderate agreement (Cohen's Kappa = 0.76), and the remaining 90% of the sample was therefore divided between

Discussion

This review has identified and mapped quantitative studies exploring the effects of nurse prescribing on medication and patient outcomes. Our results support the findings of the previous review (Van Ruth et al., 2008). Our findings suggest that nurses prescribe for a wide range of patients and in comparable ways to physicians. Overall, nurses appear to prescribe for just as many patients as physicians do, nurses prescribe comparable numbers of medicines per patient visit and there appear to be

Conclusion

Nurses prescribe in comparable ways to physicians and the effects of nurse prescribing on medication and patient outcomes are similar or better when compared to physician prescribing. However, due to methodological weaknesses in this body of research, conclusions must remain tentative. More randomised controlled designs in the field of nurse prescribing are required to enable definitive conclusions about the effects of nurse prescribing.

Author contributions

JD, SG and MK contributed equally to the study and share joint first authorship. All the authors contributed substantially to the study and approved the final version. PM, JD and SG developed the search strategy. JD and SG carried out the literature search. JD and SG extracted all study data and MK checked all the data extracted. JD, SG and MK wrote the first draft of the paper and PM and AF contributed to subsequent drafts.

Conflict of interest

No conflicts of interest have been reported.

Funding

This study was funded by a grant to NIVEL from the Dutch Ministry of Education, Culture and Science.

Ethical approval

Not required.

Acknowledgements

This is an update of Van Ruth L, Francke AL, Mistiaen P: Effects of nurse prescribing of medication: a systematic review. Internet Journal of Healthcare Administration 2008, 5: http://dx.doi.org/10.5580/11e, URL: http://ispub.com/IJHCA/5/2/3311. The review authors acknowledge and thank Lotti van Ruth who was lead author of the original review. She gave permission to update the review and use the original data in the update. She has read and approved the final version of this update.

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