In rutinary clinical practice, nurses plan actions to respond to patient's healthcare needs and they implement prescriptions in the majority of cases. These prescriptions (either health interventions, drugs or other healthcare products) help to resolve, improve, stabilise, avoid complications, provide wellbeing or improve patient's health status. In spite of this context, the current legislation does not allow nurses to fully implement in an easy and nominal manner these actions. In the United Kingdom (UK), pharmacists and nurses are authorised to prescribe as non-medical prescribers. In other countries, such as the United States, Australia, Canada, Finland, New Zealand, Norway, Holland or Sweden, including Spain, nurses have the authority to prescribe but with restrictive legal requirements.1 According to a more recent study based on an expert survey and data from the OCDE 2nurses specialists in Ireland, Netherlands and independent nurse prescribers in UK can prescribe most medicines, while they are set to some selected drugs in Cyprus, Denmark, Estonia, Finland, France, Norway, Poland, Spain or Sweden. All countries have regulatory and minimum educational requirements to prescribe and most with medical doctor's supervision.2 It should be noted, that nursing prescription goes beyond medicines and drugs, and apply to any kind of health intervention, medical devise or health product.

At state level, several publications summarize the evolution of nurse prescription in Spain over the past years and is further summarized in the Online Appendix 1.3–6 Nursing prescription has evolved from an extra-legal framework to an implicit legality, from an explicit illegality to a legal context were a full implementation is still expected.5 In the case of Catalonia, NP is not covered by any specific legal framework. When the Royal Decree 1302/2018 was published on nurse prescribing which regulated the indication, use and authorization of dispensing of medicines and health products for human use by nurses, a positioning paper was made by the Council of Nursing College of Catalonia. The positioning was that it provided greater legal coverage for nurses compared to previous initiatives, even though it was far from establishing a regulation for an effective implementation. In this context, a pilot study gathered the opinion of primary care and community-based health professionals regarding NP and its perceived benefits in a specific health area close to Barcelona in 2015.7,8 In order to further advance in understanding the opinion on the benefits of NP, a wider consensus study was carried out open to health professionals and managers working for the Catalan healthcare system, also as a strategy to generate collective intelligence and knowledge transfer round this topic and is the basis of the present study (Fig. 1).

Figure 1.

Conceptual background of the study on the opinion and consensus on nurse prescribing and its benefits in the Catalan healthcare system. NP: nurse prescribing.

(0,31MB).

The general objective of the study was to describe the positioning and level of consensus on the benefits of nursing prescription in Catalonia by nurses and other health professionals.

A total of 1332 healthcare professionals and managers participated and voted the 12 items (benefits of NP). Of these, the majority were nurses (74.9%), medical doctors (18.5%) and performed healthcare activities (65.4%). As for the professional field, the majority of participants worked in primary and community-based healthcare (44.4%) or acute hospitals (36.3%) (see Online Appendix 3).

All items measuring the benefits of nurse prescription scored globally a median of 5 to 6 (6 maximum score) by participants (n=1332). Additionally, fifty percent of items reached a high level of consensus on these benefits (data available on request) and the other 50% a moderate level of consensus globally. These results indicate a generalised positioning in favour of NP for professionals participating in the present study.

Effect sizes show moderate to high differences in items (benefits) comparing the standardized differences of nurses with medical doctors scores, as well as nurses with pharmacists scores (Table 1). Differences were null or small for other variables analysed (data not shown and can be obtained on request). Nurses participating in the present study showed a high degree of consensus for the following benefits of NP (median scores between 5 and 6 and IQR between 0 and 1) (Tables 1-3):

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  Empowers the nursing profession.

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  Favours leadership of the nurse in the care process.

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  Necessary among the skills of nurses.

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  Favours person-centred care.

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  Contributes to better empathy and healthcare continuity.

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  Improves other aspects of healthcare quality.

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  Improves resolution of the healthcare process.

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  Increases the feeling of support from their collective to become a NP.

Half (50%) of the medical doctors that participated gave a score of five or more (scale of 1 to 6) for almost all the benefits considered for NP in the Health Consensus. Nevertheless, when the scores (votes) for the benefits of NP were stratified and standardised they showed moderate (effect size between 0.6 and 0.8) to high (effect size above 0.8) differences when compared to the nursing collective for almost all the items assessed (Tables 1-3).

Medical doctors had an opinion similar to nurses regarding the following proposed benefits of NP:

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  Increases independence and responsibility of the nurse.

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  Favours a more balanced distribution of responsibilities among professionals.

The degree of consensus for the benefits of NP was lower in the pharmacists participating in the study, who valued the advantages of NP far below the perception of nurses (the magnitude of the differences between these two groups was high ES>0.8). Nevertheless, pharmacists showed a moderate degree of consensus (IQR between 1 and 2) and 50% gave a score of five or more (scale from 1 to 6) in relation to the fact that NP increases nurse independence and responsibility. Finally, in the group of “other” professional disciplines, the scores for the 12 items (benefits of NP) seemed to be practically the same as the standardised scores for nursing profiles. The group of “other disciplines” showed a moderate to high degree of consensus regarding the benefits of NP.

To our knowledge, this is one of the widest consensus study on nurse prescription and its benefits in the Spanish National Health System. In general, there was agreement on the benefits of NP by participants. When stratification of scores was made by their discipline, nurses seem to score higher and reach a highest level of agreement in most benefits included in the Delphi study.

The main barriers of nurse prescription documented in the literature are cultural and corporative (values and beliefs that limit the discipline and rule the biomedical care context), institutional (rules, regulations, protocols) and organizational (funding and leadership). A potential barrier could be the unawareness of what prescription implies in real clinical practice and thus, generating a differential positioning on nurse prescription and the level of agreement on its benefits. These barriers have been studied in various systemic reviews of the evidence identified.1,14,16 Additionally, personal skills and attitudes such as confidence or professional leadership are seen as facilitators in the implementation of nurse prescribing. Regarding system barriers, participants in Noblet et al.14 review include the support and facilitation by existing regulatory frameworks, motivation, funding for continuing education, key strategic approaches and health planning. Based on the factors identified, a conceptual framework was proposed to facilitate decision-makers to implement the prescription of non-medical professionals safely.

Graham-Clarke et al.16 concluded that prescription by non-medical professionals (mainly in the field of nursing and pharmacy, as well as physiotherapists) encourages independence, professional satisfaction and supports professional development. Nevertheless, some studies included reported that the prescribing process resulted in additional anxiety and a certain caution among the professionals involved. Regarding perception of knowledge and skills, in a study from the Netherlands,17 from 386 participant nurses in 2006 and 644 in 2012, only 12% of them considered they were not adequately prepared to prescribe medicines. In a study led in the Spanish context, participating nurses perceived they had better knowledge than primary care physicians do on drugs and medical devices based on available guidelines recommendations for the prevention and treatment of pressure ulcers.18 In a similar study,19 nurses considered that they give better advice about disease and its treatment than medical doctors do. It pointed out that a holistic view of their practice and a greater opportunity to involve their patients could be key aspects for these perspectives.17

Apart from the savings factor (efficiency) and improved quality of healthcare, other benefits of prescribing documented are the improved image of the profession, as well as a gain in independence and therefore, less dependence on the primary healthcare physician or other professionals when attending the needs of patients.16 In this context, the field of “nurse prescribing” will be a hot topic in many areas of care in the near future: the replacement of the nurse in acute care20 or in chronic care, such as diabetes.19 An adequate preparation will be required for the expansion of the scope of independent prescribing for nurses.21,22

Azucena Santillán-García.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

G. Jodar-Solà, A. Brugués-Brugués, V. Serra-Sutton and J.M. Monguet-Fierro contributed to the conceptualisation of the research. G. Jodar-Solà, V. Serra-Sutton and M. Espallargues-Carreras contributed to the funding acquisition and provided the resources to carry out the research. J.M. Monguet-Fierro and A. Trejo-Omeñaca provided the software used in the study. V. Serra-Sutton, A. Trejo-Omeñaca and J.M. Monguet-Fierro were involved in the data curation and its formal analysis. M. Espallargues-Carreras supervised the study. V. Serra-Sutton, G. Jodar-Solà and A. Brugués-Brugués wrote the original draft. All coauthors participated in the proposal and revision of statements included in the consensus. All coauthors contributed to the recruitment of participants/institutions. All coauthors participated on the discussion of results. All coauthors reviewed the original draft and contributed to the final version.

The present project was commissioned to the Agency for Health Quality and Assessment of Catalonia (AQuAS), a public governmental organization and has been co-leaded in close collaboration with COIB, AIFICC, Onsanity and UPC. We would like to acknowledge the support and collaboration of professionals participating in the project, health providers and health regions in Catalonia who have stimulated participation and dissemination of the project. Specifically we would like to thank the following organizations and representative professionals who have been members of the advisory committee of the present project (see Annexed).

The present study has not received a specific funding. The Agency of Health Quality and Assessment of Catalonia (AQuAS) signed a collaboration agreement with the Council of Nurses and Infermers Colleges of Catalonia (CIIC) and the Family and Community Nursing Association of Catalonia (AIFiCC) to carry out the study. The project was partially financed by AQuAS and the budget of Group 15 of the Spanish scientific network Consorcio Centro de Investigación Biomédica (CIBER) in Epidemiology and Public Health (CIBERESP). The Spanish Biomedical Network- CIBER financed the Health Delphi platform applied in this consensus study. The revision of English grammar was carried out by a native linguist financed by the CCIIC.

The authors express they have no conflict of interest and have completed the conflict of interest declaration proposed by the ICMJE. Nevertheless, we would like to express the following: G. Jodar and A. Brugués represent the Council of Nurses’ Colleges of Catalonia (CCIIC) and the Association of Family and Community Nursing of Catalonia (AIFiCC). AQuAS contributes to fostering independence in the project development process, the analysis of results, discussion and conclusions/recommendations, together with Onsanity and the Universitat Politècnica de Catalunya (UPC). This collaboration has facilitated the implementation of a rigorous and transparent methodology to analyze the position and opinion on nursing prescription in Catalonia. It should be mentioned that to minimize any potential conflict of interest linked to the COPI study; a wide group of professionals representing key entities has been invited to be part of the project's advisory committee. Regarding the academic profiles of the authors: G. Jodar and A. Brugués are nurses and work in the field of clinical management and are managers in primary health care teams; V. Serra-Sutton is a sociologist and health service researcher working at AQuAS, she is also head of the scientific group representing AQuAS at the CIBERESP, and M. Espallargues is a doctor specializing in preventive medicine and public health and is responsible for the scientific and quality area at AQuAS; J.M. Monguet and A. Trejo are industrial engineers, researchers and teachers in innovation at the UPC. In addition, A. Trejo is director of Onsanity Solutions S.L.