International Journal of Nursing Practice 2005; 11: 102–107

R Fisher

Correspondence: Rick Fisher, School of Health Sciences and Social Care,Brunel University, Borough Road, Isleworth, Middlesex TW7 5 DU,United Kingdom. Email: rick.fisher@brunel.ac.uk

✠ R E S E A R C H P A P E R ✠

Relationships in nurse prescribing in district nursing practice in England:

A preliminary investigation

Rick Fisher RGN DNT BA(Hons) MScLecturer in Community Health, School of Health Sciences and Social Care, Brunel University, Isleworth, Middlesex, United Kingdom

Accepted for publication November 2004

Fisher R. International Journal of Nursing Practice 2005; 11: 102–107Relationships in nurse prescribing in district nursing practice in England: A preliminary investigation

Nurse prescribing is a significant change in the working lives of district nurses in the United Kingdom. It has been achievedas the result of a 13-year sociopolitical struggle, eventually culminating in an Act of Parliament, which enabled selectednurses to prescribe from a limited formulary. This research attempts to discover the nature of its impact on the relation-ships between prescribers, nurses, doctors, pharmacists, patients and carers. Using a qualitative approach, guided inter-views were carried out with nurses, doctors, pharmacists, patients and carers. Initial findings indicate that far fromproducing an independent prescribing workforce, some prescribers are reverting to their preprescribing behaviour. Forthese prescribers, there is a suggestion that old hierarchies are being reinforced, which might be detrimental to nurse pre-scribing.

Key words: district nurses, hierarchy, prescribing, primary care, relationships.

INTRODUCTIONThe purpose of this article is to disseminate some of theearly findings of an ongoing research project which isexploring the professional relationships that exist betweendistrict nurse prescribers and others in the English pri-mary care system.

By way of definition, James and Low considered a dis-trict nurse to be:

A qualified registered nurse who has been especially trained topromote health, provide skilled nursing and health care topeople in their own homes, wherever this may be. She/he leads

a team of nursing staff and ensures that this care is appro-priately planned and delivered to those who need it whilst atthe same time making sure that other family members receivethe help and support they need.1

To become a district nurse, one must first undergo aperiod of three years’ education and practical experienceto be registered with the regulatory body, the Nursing andMidwifery Council, as a registered nurse. Following this,it is necessary to gain at least two years’ experience ina clinical area before being accepted for district nurseeducation.

In the United Kingdom (UK) in 2004, the preparationfor district nurses is of at least degree-level and many suchcourses are also offered at postgraduate or Masters level.On successful completion of the course, the nurse isawarded the title of ‘Specialist Practitioner’ and is, among

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other activities, licensed to prescribe items from theNurse Prescribers’ Formulary (NPF). This activity is sig-nificant because, at the current time, it is a role which, inthe primary-care nursing arena, is exclusively reserved fordistrict nurses and health visitors.

Prescribing has arrived in community nursing througha tortuous route. Baroness Cumberlege indicated that thehistory of nurse prescribing in England has been fraughtwith difficulty, burdened by a social struggle in which‘nurse prescribing became a giant cultural hurdle to turnhandmaidens into autonomous practitioners’.2 Describingthe project as part of the feminist revolution, which per-meated British life, she considered that nurse prescribing‘triggered a wholesale reassessment of the role of nurses,their training and the move to a profession qualified withdegrees in nursing’.2

Cumberlege first mooted prescribing by nurses in1986.3 The subsequent Crown Report indicated that,among the benefits which were to be gained from nurseprescribing, were:4

1. Improved use of both patients’ and nurses’ time.2. Improved patient care.3. Improved communication between team members as aresult of clarification of professional responsibilities.It can be readily seen from the above that the claims madefor nurse prescribing by its proponents are grand and thatexpectations on behalf of the professions and politicianswere understandably very high.

The primary role of the district nurse is to act as theleader or manager of a team of other nurses who deliverspecialist nursing care to people in non-hospital settings.Sole responsibility for the day-to day management ofpatient care lies with the district nurse, although manyof the actual tasks involved in providing this care aredelegated to other team members according to theirqualifications and experience. In order to discharge thisresponsibility, district nurses need to develop and main-tain relationships with others in order to provide an excel-lent service for those in their care. The latter of thebenefits suggested by the Crown Report depends upongood working relationships between all of those involvedin the process of prescribing.

Aims of the studyThis paper is drawn from an ongoing project which isexamining the ways in which all of those players involvedin the act of nurse prescribing relate to each other. Beingqualitative in nature, it seeks, initially, to describe and, in

the fullness of time, explain how these relationships oper-ate. The paper aims to enlighten the reader’s understand-ing of the ways in which district nurses feel their workingrelationships in the arena of nurse prescribing have beenaffected by this relatively new role. Specific aims are:1. To describe some aspects of the relationships betweennurse prescribers and general practitioners (GPs).2. To demonstrate that prescribing is affecting the rela-tionships between nurse prescribers and others.3. To develop a preliminary explanation of the changesthat are taking place.

METHODSThe study began in early 2003 and is taking place in a vari-ety of urban–metropolitan, suburban and rural areas insouth-eastern England. As is the case with qualitativeresearch, the purpose of this study is not to demonstratenumerically the significance of a particular action or set ofactions but to describe and, to a certain extent, explainthe social phenomena concerning the relationships whichare being observed. In order to achieve this, the chosenmethodology for this study is ethnographic in character. Inethnographic work, the aim is to examine the detail ofpractices and interaction in ‘real time’ as it happens and,as far as possible, in a naturalistic way.5 That is, theresearcher interferes as little as possible in the interactionswhich are being observed in order to gain information onkey elements of everyday practice. The research is beingundertaken through the use of semistructured interviews,after Lofland.6

Access to participants has proved to be the single mostdifficult aspect of this project to date. Numbers of respon-dents have been very low, six at the time of writing. It ishoped that this will be rectified by using a group interviewtechnique, wherein participants will find support andcomfort, rather than being exposed to individual scrutiny.Nevertheless, those interviews which have been con-ducted have revealed rich data concerning relationships innurse prescribing.

Interviews were tape-recorded with the written con-sent of the participants. In order to guide the initial pilotinterviews, a number of topics were incorporated into theinterview guidelines, which were used as an aide memoire.The topics were grouped under the headings ‘Issues aboutprescribing’ (Appendix I) and ‘Issues about relationships’(Appendix II).

To help the conversation flow, topics were covered in arandom order, with the interviewer checking that all were

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covered by referring to the aide memoire. Interviews wererecorded using a Sony minidisc recorder (Sony Corpora-tion, Tokyo, Japan). After the recording process, the inter-views were transcribed verbatim following a pattern oflistening to the whole recording once and then reviewingresponses to each question.7

After using the interview guidelines, some significantcategories emerged which helped to inform the subse-quent interviews. Topics broached by interviewees wereincorporated into ensuing interviews in an iterative fash-ion after Glaser and Strauss8 in order to provide checks forinternal validity between respondents.

AnalysisAt this early stage, analysis has proceeded using visual com-parison of transcripts. As the number of respondents todate is small, this means that initial comparisons of data canbe made manually. Interviews have been transcribed intotabular form and emergent themes have been highlighted.As the work progresses and the numbers of respondentsincrease, it is intended to employ the QSR NUD*IST dataanalysis package (QSR International, Doncaster, Vic.,Australia) to manage larger quantities of data. Utilizing thevisual process,the following categories have emerged inwhich respondents have discussed nurse prescribing:

• Recording prescribing actions

• Prescribed items

• Relationships with GPs

• Relationships with other nurses

• Relationships with pharmacists

• Relationships with patients and carers

Ethical considerationsPilot interviews were carried out with two district nurseswho were prescribers. Verbal informed consent wasobtained for these interviews, which were undertakenprimarily to formulate the interview guide. Permission toundertake the ensuing research was granted by the localresearch ethics committees which govern the areas wherethe research is taking place. Procedures for seeking ethicalpermission are rigorous and require that written informedconsent is obtained before the research can be conducted.The interviews, which are recounted in part in this arti-cle, were all subject to this consent being granted.

The participantsAll of the participants in this aspect of the study werequalified district nurses. They were all employed by the

National Health Service and being licensed to prescribefrom the NPF was a necessary feature of their employ-ment. For the purpose of this paper, these prescribershave been described as A, B, C, D, E and F. They possessedthe following characteristics: A and B worked in a largemetropolitan area and both had been prescribing for 2.5years at the time of the interview; C worked in a large,purpose-built health centre servicing a large county townand had been a qualified prescriber for two years; D and Ewere employed in different rural practices where they hadboth been prescribing for 3.5 years; they all worked full-time; F also worked in a rural practice but on a part-timebasis; with the exception of C, who said she prescribed‘once a month’, all related that they prescribed on a fre-quent basis.

FINDINGSAlthough several categories have emerged from thisresearch to date, this account will focus on issues concern-ing recording prescribing actions in order to explore thisarea in some detail.

Recording prescribing actionsIssues concerning the administrative processes involvedwith nurse prescribing were identified by all partici-pants. Recording the prescribing actions taken is animportant aspect of prescribing and nurse prescribersare legally obliged to record such action in the patient’sGP-held notes within 48 h. This is to lessen the risk ofdifficulties with patient allergies and other idiosyncra-cies. In the worst case, there could be potentially fatalconsequences of over-prescribing some items, such asparacetamol. Although computer technology hasimproved communications between the various profes-sionals involved in prescribing, a prescription written inthe patient’s home will need to be recorded on acomputer database to comply with the aforementionedregulations. Various methods have been adopted byprescribers to facilitate this obligation. Prescriber Brelated the following:

It does take some time to write all these prescriptions; fortu-nately our GPs, well, the computer people, they are very good.We just have to put the duplicate piece of paper into the boxand they enter it into the computer immediately. So, there isno problem for us but I know in other places they have thattrouble . . . where the nurses have to go and enter it into thepatient . . . document it, you know.

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For Prescriber D, a different approach was used:

So, we’ll give it a week and if I’m not the one who goes in aweek’s time to assess, if it’s my E grade (staff nurse) who goesin and, therefore, she’ll just pop the list onto the computerand then it’ll all be prescribed from the surgery on thecomputer.

This suggestion that it is easier to use a computer thanto write a prescription was also explained by Prescriber E,who demonstrated an interesting approach to the issues ofadministration. This involved an almost ‘non-prescribing’method, which suggests reverting to previous behaviourand was demonstrated thus:

But with both practices here I’ve always had complete freedomto put anything on the computer that I felt the patients wouldbenefit from, not medication obviously, but things that Iwould normally prescribe, dressings or catheters. If I didn’twant to do a hand-written prescription, or before I was a nurseprescriber, I could just put it on the computer and print outthe prescription and ask the doctor to sign it. And I’ve neverbeen questioned because I think the doctors are quite happy forme to do that and . . . they think, well, ‘they know whatdressings are best, catheters are best and let’s get on with it’.

For Prescriber F, the issue had been approached by GPsin a way which contradicts the legal requirement of nurseprescribing:

People got really hung up about this ‘within 24 h I’ve got towrite this up in the GP notes’. Well, they’d been prescribingfor several years and they’d actually been asked by the GPs:‘Please don’t write in our notes, you’re filling our notes upwith four-layer bandage this, this and this. If you prescribesomething new or different, we would like to know if you pre-scribe a medicine, but to be honest, if it’s dressings and we’vegot it on the computer and that prescription’s come in andbeen issued to that patient, we would rather you didn’t doc-ument it. Document it in the nursing notes but don’t docu-ment it in the GP notes.’ You know, they did try, they weregoing to have a special form that they were going to fill it inand keep with the GP notes but, with four-layer bandaging,there’s a lot of things to keep writing and especially if you’retrying not to order too much so that you don’t get too muchbulk in.

Prescriber C had an altogether different approach:

So, I think as long as I’ve documented it somewhere or I’vephotocopied it . . . if you photocopy, it’s great ’cos it just goesinto the patient’s base notes and maybe I’m supposed to writeit somewhere and maybe I’m not; I’m not gonna write thesenumbers down all over the place because . . . another girlactually does carbon copies . . . I think ‘Oh, I can’t be faffedwith this’. I think I’m legal, what I do is legal. I’m not justgoing to do all this, the more you duplicate something, themore errors you can get.

It appears from these accounts that district nurse pre-scribers are pursuing a pragmatic approach to docu-menting action taken. Administrative processes areviewed by many as a ‘necessary evil’. Nurses recognize,in their Code of Professional Conduct,9 that they mustmake contemporaneous notes of all their nursingactions, and prescribing is not an exception to this rule.Cumbersome procedures have been streamlined bysome, as illustrated by Prescriber B. Others, though,have taken action which suggests that the act of prescrib-ing itself is problematic. When Prescribers D and E talkabout ‘putting it on the computer’, they are reverting toactivity which was commonplace before nurse prescrib-ing was introduced. In such arrangements, many nurseswould ask a pharmacist for an item to be supplied andwould then seek the prescription from a GP to legiti-mize their action.

It is apparent in the examples given above that theseprescribers find it easier to request an item by fillingdetails into a computer programme, rather than takingprescribing action themselves. A more ominous interpre-tation would be that, in taking such action, they are avoid-ing the responsibility of writing a prescription and,therefore, being accountable for that action. Whatevertheir reasons, there is some evidence to indicate that thisaspect of prescribing activity causes difficulty for someprescribers.

With regard to the situation described by Prescriber F,there is concern that, regardless of the nurses’ legal obli-gation, the local ‘policy’, if it can be described as such, isthat the GPs do not want their notes cluttered by nursingprescriptions. The doctors in question have expressedtheir discontent at the legitimate process and have coun-termanded it by introducing a ‘local’ interpretation. Thisraises important questions about legality and, importantlyfor this research project, does seem to indicate that, in thissituation at least, the doctor–nurse hierarchy is firmly inplace.

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Implications for practiceNurse prescribing was initially intended to improve theservice to patients and also to elevate nursing’s standing asa profession in its own right. Nurses who prescribe canmake a significant, positive impact on the well-being andtreatment of patients in their care. Although the NPF islimited, there is scope for it to be extended and somemodifications have already been made. However, there isconsiderable tension between the intentions of this legis-lation and the delivery of prescribing in practice. The sit-uation is not constant and is more complex than it mightat first seem. The examples used in this paper have dem-onstrated that some nurse prescribers appear less thancomfortable with the administrative aspects of prescrib-ing. Several of the respondents in this research have dem-onstrated that, in spite of gaining a qualification whichallows them to prescribe legally, they have reverted toprevious patterns of behaviour. This is evident in theordering of products for patients using a computerizedsystem.

Besides creating a dual system, which may run in par-allel to the ‘official’ nurse prescribing route, this has thecapacity to seriously affect nurse prescribing. This canoccur in two ways. First, by circumventing the ‘official’system, nurses risk perpetuating the hierarchical relation-ship between prescribing doctors and non-prescribingnurses. There are indications in the above accounts that,regardless of the legislation, nurses are still being con-trolled by doctors. In some cases illustrated in this paper,they are still seeking permission to perform their roles incertain ways. This is couched in the language used whenPrescriber E talks about having ‘complete freedom’ toprescribe and, at its most extreme, is the example of Pre-scriber F, who, along with her colleagues, is contradictingthe legal requirement to record in the patients’ notesbecause the doctors insist this should be so. Second, andperhaps more importantly for nursing, those practitionerswho do not prescribe stand the risk of becoming deskilledover time.

CONCLUSIONSThis paper provides some insights into the ways in whichnurse prescribers are relating to GPs in the course of theirprescribing practice. Findings show that although legisla-tion exists which has created a degree of independencefrom doctors in the arena of prescribing, for somepractitioners it appears that a reversion to, or maybe acontinuation of, previous ‘non-prescribing prescribing

behaviour’ is the easier way to practice. Although thesefindings cannot be considered to be generalizable, there isa clear suggestion that, in some areas at least, the reality ofprescribing behaviour in practice is contradicting thatwhich theory suggests it ought to be. In some cases, farfrom releasing nurses from a subservient ‘handmaiden’role as described by Cumberlege, the hierarchical normsseem to be reinforced.

REFERENCES1 James E, Low H. The District Nurse. RCN District Nurse Forum.

London: Royal College of Nursing, 1990.2 Cumberlege J. Foreword. In: Humphries J, Green J (eds).

Nurse Prescribing. Basingstoke, UK: Palgrave Basingstoke,2002; xi.

3 Department of Health and Social Security. NeighbourhoodNursing: A Focus for Care. (Cumberlege Report). London: HMSO,1986.

4 Department of Health. Report of the Advisory Group on NursePrescribing. (Crown Report). London: Department of Health,1989.

5 Hammersley M, Atkinson P. Ethnography: Principles in Prac-tice. London: Routledge, 1995.

6 Lofland J. Analyzing Social Settings. Belmont: Wadsworth,1971.

7 Fielding N, Thomas H. Qualitative interviewing. In: GilbertN (ed.). Researching Social Life, 2nd edn. London: Sage, 2001;123–144.

8 Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strat-egies for Qualitative Research. New York: Aldine Publishing,1967.

9 Nursing and Midwifery Council. Code of Professional Conduct.London: Nursing and Midwifery Council, 2002.

APPENDIX IIssues about prescribing

1. How long have you been a prescriber?2. How frequently do you prescribe?3. What are the items you most frequently prescribe?4. What sort of conditions do you prescribe for?5. Please tell me about the types of patients who you pre-scribe for.

APPENDIX IIIssues about relationships

1. In what ways has your day-to-day practice beenaffected by your prescribing activity?2. Who are the professionals with whom you have regu-lar communication about prescribing issues?

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3. How has your working relationship with other profes-sionals been affected by your prescribing activity?4. Has prescribing had an effect upon the frequency andtypes of contacts you have with other professionals?

5. How do you feel your relationships with other profes-sionals may change if there is a further extension to nurseprescribing?