How do nurse prescribers integrate prescribing in practice: case studies in primary and secondary care

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Abstract
Aims and objectives: To report a study investigating how nurse prescribers integrate prescribing in clinical practice. Factors that influence integration are explored and how nurses approach integration is defined.Background: There are expectations that nurse prescribers will prescribe for patients. Nurse prescribers share jurisdiction of prescribing with doctors in the workplace and new divisions of labour must be agreed to enable the nurse to begin prescribing. Little is known about how nurses integrate prescribing in practice but these agreements are potentially important to the organisation of professional work and the delivery of healthcare.Design: Case study.Methods: Twenty six nurse prescribers were interviewed in case studies of primary and secondary care prescribing. Case data were collected by semi‐structured interview and combined with field notes and socio‐demographic data in case summaries. Data were organised in nvivo (QSR International Pty Ltd, Doncaster, Victoria, Australia) and subject to manual analysis at single and cross‐case level.Results: Twenty‐one of the 26 cases were prescribing. Trust between doctor and nurse and nurse and employer was shown to be necessary for effective integration. There were differences in how prescribing agreements were reached in primary and secondary care. Restrictions were imposed in secondary care. In primary care, nurses made decisions themselves about the medicines they prescribe but frequently asked doctors to check their decisions. Nurses described three approaches to prescribing: as opportunity presents, for specific conditions and for individuals.Conclusions: Nurse prescribers described three approaches to prescribing and in two approaches the nurse self‐restricted prescribing activity. Secondary care prescribers had more employer restrictions than their primary care counterparts. Trust between doctor nurse and nurse employer was shown to be necessary for integration; without trust, the nurse will not prescribe.Relevance to practice: Trust in prescribing relationships is necessary for effective integration of nurse prescribing in practice.

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