Family Practice 2012 Cousins 223 7

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The Author 2011. Published by Oxford University Press. All rights reserved.

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Family Practice2012; 29:223227

doi:10.1093/fampra/cmr077

Advance Access published on 28 September 2011

Nurse prescribing in general practice: a qualitative

study of job satisfaction and work-related stress

Rosanna Cousins* and Christine Donnell

Department of Health Sciences, Liverpool Hope University, Liverpool, UK.*Correspondence to Rosanna Cousins, Head of Health Sciences, AEW208, Liverpool Hope University, Taggart Avenue,Liverpool L16 9JD, UK; E-mail: [email protected]

Received 1 March 2011; Revised 31 July 2011; Accepted 22 August 2011.

Background. Studies examining the impact nurse prescribing have largely focused on the effi-

cacy of the service. It was suggested in pro-prescribing policy arguments that extending the

nursing role to include prescribing would increase job satisfaction. This assertion has not been

fully explored.

Objectives.To investigate the impact of independent prescribing for experienced nurse practi-

tioners (NPs) working in general practice.

Methods.In-depth interviews were conducted with six NPs who each had at least 3 years expe-rience of independent prescribing in a busy inner city general practice.

Results. Analysis of interview data yielded two main themes: as independent prescribers NPs ex-

perienced increased levels of both job satisfaction and work-related stress. Increased satisfac-

tion was associated with having greater autonomy and being able to provide more holistic

care. Increased work-related stress emerged from greater job demands, perceived insufficient

support and perceived effortreward imbalance that centred upon the enhanced role not being

recognized in terms of an increase in grade and pay.

Conclusions.Independent prescribing increases job satisfaction for NPs in general practice,

but there is also evidence of stressors associated with the role. It is important that NPs in gen-

eral practice are encouraged and supported towards providing the effective patient-centred

care in the community envisaged by current UK government. We acknowledge that the

results presented in this paper are based on a sample limited to one city; however, it provides

information that has important implications for the well being of NPs and ultimately patient

care.

Keywords. General practice, job satisfaction, nurse prescribing, qualitative, work-related

stress.

Introduction

The introduction of nurse prescribing in the UK in 1992was underpinned by recommendations of the Depart-ment of Health advisory group report;1 known as the firstCrown Report, it included various supportive clinical ar-guments and additionally asserted there would be an in-crease in job satisfaction for nurses. Job satisfaction isold construct that has stood the test of time. It is a combi-nation of psychological, physiological and environmentalcircumstances that cause a person to assert that they aresatisfied with their job.2 It assesses the difference be-tween an individuals expectations, and what he or sheactually experiences. Such a definition indicates a varietyof variables that influence the satisfaction of the individ-ual. So, although job satisfaction is a unitary concept,the causes of this overall attitude are multidimensional.3

There is general support for the premise that pre-scribing increases job satisfaction for nurses.46How-ever, extant studies have largely focused on thepositives, without due consideration of any negativeaspects, there may be in taking on the extended role.The nursing profession is known to have high preva-lence rates of work-related stress,7,8 and potentials forstress in general practice have also been documented.9

It is estimated that 14 000 nurses now have al mostthe same prescribing rights as doctors in the UK,10 al-though the number of nurse-independent prescribersin general practice has not reached predicted levels.11

A recent survey in one English county indicated that


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in being treated by a nurse prescriber.1214 There areno studies that are specific to nurse prescribing in gen-eral practice to explain the relatively low numbers ofnurse practitioners (NPs) who are also independentprescribers.

The aim of this study was to investigate the full im-pact of becoming an independent prescriber for NPs

in general practice. In addition to confirming Crownsassertion that independent prescribing increased jobsatisfaction, we additionally explored whether the ex-tended role made a difference to potentials for stressin NPs.

Methods

Design

A qualitative approach was chosen. This was most ap-propriate towards teasing out the longitudinal elementof the research. In-depth semi-structured interviews

were used to collect rich data describing the context,perceptions, actions and emotions of participantsin relation to job satisfactions and dissatisfactions inrelation to nurse prescribing in general practice.

SamplingSix NPs who were also experienced independent pre-scribers were interviewed (five females and one male;aged 3648 years). All had held the qualification Regis-tered General Nurse (RGN), for at least 10 years, and,in line with the inclusion criteria of the study, all partici-pants had held the qualification V300independentand supplementary nurse prescribing for at least 3

years. All the participants were autonomous practi-tioners, running their own clinics in one of the four sep-arate sites of a group practice in Liverpool, UK. Fullclinics and issuing several computer-generated prescrip-tions during each clinic was the norm. All the practiceclinics operate during the hours 8:3018:30 undera booking system; additionally, the one site purposelyserving the large student community in the city hasa walk-in clinic during the hours 8:3016:00 duringterm-time. While the sample size is small, it is represen-tative of the number of NPs meeting the criteria in thecity. This type of study often includes a small cohort.15

Additionally, there is some confirmation of the suffi-

ciency of a sample size of six for a qualitative study,16

and here, there was evidence of reaching saturation af-ter six interviews.

Data collection and analysis

Individual semi-structured interviews of up to 2 hourswere undertaken with the NPs in their homes, at a timeof their convenience. The interviews explored thechanges in their job since becoming independent pre-scribers; indicative questions included How has your

job changed since becoming a prescriber?, What are

the advantages/what do you enjoy about being a pre-scriber? and What are the disadvantages/difficultiesof being a prescriber? A digital voice recorder wasused to aid transcription, and additionally, contextualnotes were made by the interviewer. The data werefully transcribed and then analysed using content the-matic analysis. Inter-rater reliability was checked.

There is no easy way to ensure the reliability or objec-tivity of judgement-based nominal data: the best ap-proach relies on the evaluation of the judgements oftwo or more independent coders.17 In this study, tran-scripts of the six interviews were first coded in full bythe authors and then another independent experi-enced researcher agreed to read all six transcriptsand code the data (Consent was obtained from allparticipants prior to sharing the data.). Holstis for-mula 2m/N1 + N218 was applied to determine the in-ter-rater reliability. This was calculated >80%,allowing the data to be considered reliable. The dis-agreements were resolved by reference to the field

notes and the interviewers judgement.

Results

Four themes were identified from the interview data:benefits of nurse prescribing, which had three subthe-mesincreased control, greater autonomy and moreholism in role; increased job demands, support issuesand lack of reward. Further reduction of the dataproduced two overarching concepts: increased jobsatisfaction and work-related stress.

Benefits of nurse prescribingAutonomous practice was found to be pivotal to theenhanced job satisfaction reported by all six NPs whowere also independent prescribers Figure 1. Being ableto complete an episode of care for the patient, whichpreviously would not have been possible if a prescrip-tion was required, was key. Before becoming qualifiedindependent prescribers, at the very least, the NPswould have had to have a GP sign off even routine re-peat prescriptions. NP2 stated Its just that it makesmy job easier. The fact that I can give patients medica-tions, I can give them what they need rather than

FIGURE 1 Themes from content analysis of interview data

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consult with someone else. I enjoy that, treat them my-self rather than get someone else to do it for me, I en-

joy that. Similarly, NP3 answered I enjoy it because Ican finish the whole consultation; because I dont haveto wait for other people to finish the care and I think Igive the best service to the patient. NP3 suggested thata patient has got a lot more faith in you if you can tell

them you need to be taking this, rather than saying,Ive just got to go and check with the doctor. It under-mines the whole consultation if youve got to go andget your prescription signed.

The NPs were all positive about the prescribingrole, perceiving it as enabling them to provide a moreholistic and complete type of care. For example, NP1,a sexual health expert, said I get more job satisfactionnow because I can instigate treatment or first pills. Ifthe patient is coming for the pill, I can prescribe itand see them again. It has given me more autonomy.

The narratives strongly suggest that independent pre-scribing increases NPs confidence and self-esteem, which

in turn increases their job satisfaction. All six participantsclarified that they prescribed only within their own com-petencies, not stepping outside of them despite pressureto do so from both patients and GPs. Prescribing withinones competencies ensures safe prescribing and also en-sures that practice is in line with current NMC guidelinescontained within the NMC Code of Professional Con-duct.19 This is important within any sphere of clinicalpractice; however, it is of particular importance to NPsas independent prescribing is a relatively new role forthem. When prescribing NPs need to address medico-legal issues; prescribing when not in a position of compe-tence would not only be potentially dangerous to patients

but also indefensible should any harm occur. Being ableto professionally delineate their competencies for pre-scribing increased confidence as NPs became more expe-rienced, which in turn increased job satisfaction, and forsome participants an expressed increase in self-esteem.

There was consensus among the NPs that they couldnot go back to a non-prescribing role. Considering be-fore becoming a prescriber and her current positionNP3 said I couldnt stand outside a GPs door afterdoing all the training. Id be offended that I couldntuse it. It would downgrade the whole role and I thinknurse prescribing gives you some kudos. And as NP5observed, the patients are aware of your skills andthey know youre making decisions and prescribingfor them. It gives you a sense of satisfaction.

Autonomy, holism and increased job control were rec-ognized as advantages of the independent prescribingrole by all six NPs, with nurse prescribing in turn leadingto a perceived increase in patient satisfaction, which wasalso important to all the participants. Increased job con-trol was highlighted many times in conjunction with theprovision of holistic care and appeared to be an impor-tant positive aspect of prescribing. To reiterate, all partic-ipants stated that they enjoyed the autonomy of the

prescribing role; however, increased job control was gen-erally referred to in terms of the completion of an episodeof care and the absence of the need for medical input. AsNP6 noted with approval, I dont have to wait outsidedoctors doors anymore. I think it validates independentthinking.

The main advantages arising from the prescribing role

appear to be an overall increase in job satisfaction, whichresults from the ability to complete care autonomouslyand holistically. This involves a high amount of job con-trol, with nurses assessing, diagnosing and treating inde-pendently. Other factors contributing to increased jobsatisfaction are the enhanced status enjoyed by nurseprescribers and the increase in self-esteem, which arisesfrom patient recognition of the nurses enhanced skillsand respect from colleagues.

Lack of rewards

The increased intrinsic rewards described above, were

not, however, supplemented by increased extrinsic re-wards. All six participants clarified that NPs who go onto qualify as independent prescribers do not move upto a higher grade and are not rewarded financially. Par-ticipants felt aggrieved that the effort of attaining thequalification and the increased responsibility associatedwith independent prescribing has not been recognizedby the UK Governments Agenda for Change docu-mentation,20 which outlines the pay, terms and condi-tions for the National Health Service (NHS). The salarybanding for NPs does not include recognition for thoseworking in a prescribing role. As NP1 reported Im onthe same grade now as I was on four years ago and

didnt prescribe. This is going to be a difficult issue to re-solve in the current climate of cuts in the NHS, but therewas the suggestion in this study that the lack of increasedgrade and pay is a barrier to some NPs becoming inde-pendent prescribers and is a factor in losing independentprescribers in general practice to the profession.

The effortreward imbalance model21 argues thatstress arises where there is a belief that the efforts in-vested in a job are not appropriately rewarded, andthere was some evidence in support of this in the experi-ence of interviewing and the narratives. Participants feltunder-rewarded as independent prescribers in generalpractice. Critically, there were perceptions of a mismatchof effort and reward, which is known to be related toburnout, de-motivation, stress and anxiety.21,22

Increased job demands

Changes in job demands since becoming prescribers in-cluded the management of more complex patients, theneed for more knowledge and the need to continuallyupdate knowledge, perceived lack of sufficient consulta-tion time to deal with the more complex needs of thepatients, increased responsibility associated with diag-nosing and prescribing and the pressure to prescribe.

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Time constraints were an issue for participants, withthe main problem being consultation time given to nursesfor appointments. In line with the recent call from theRoyal College of General Physicians for 1520 minuteappointments,23 participants felt that in their specialty 10minutes for an appointment was insufficientespeciallyas this was the same time for a consultation as before they

were prescribing. Job control is decreased by the timeconstraints and where job demands are perceived as ex-cessive and not matched by reward, individuals can feelundervalued and the imbalance between effort and re-ward increases. This can result in individuals becomingde-motivated, stressed and in some cases depressed.21

Participants expressed feelings of frustration andstress during interviews and some stated that theywere having difficulty coping with their workload inthe allotted time. This was exacerbated by the pres-sure to prescribe from both medical staff and patients.Participants suggested that the expectations of GPsand patients have changed since they have become

used to having nurse prescribers, with both groups ex-pecting nurses to prescribe on a par with doctors. NP5argued I dont think all our colleagues are clear aboutnon-medical prescribing. Also, patient expectationscan cause problems. It can be hard to persuade themthat they dont actually need a prescription. Thiscauses pressure and takes up consultation time.

Pressure to prescribe was a major demand on all theparticipants and the frequency of the occurrence of thisaspect of the job demand subtheme was much greaterthan any other aspect. One nurse, felt this acutely, andwhen asked by whom, stated by patients, by people inthe practiceGPs reception. I think, once the recep-

tionist saysIll put you in with the nurse, shes a pre-scriber; the patient gets angry if its something like ananti-depressant which Im not going to prescribe. Thatsprobably the biggest challenge. It was clear that misun-derstandings around the nurse prescribing role has ledto patients being given inappropriate appointments byreceptionists, which in turn, angers patients and causesmore pressure for nurses. Nurses in this position need torefer to practice colleagues and this lack of control, inthe face of high job demands is stressful.

All the participants confirmed that working as an in-dependent prescriber affords a significant increase inclinical responsibility, and with experience, awarenessof the increase in clinical responsibility develops. Theextra responsibility combined with the pressure to pre-scribe and lack of consultation time caused partici-pants to feel stressed during busy clinics and supportwas recognized as important.

Need for supportPerceived lack of support was an issue for all the par-ticipants and several sources were identified, includingthe medical staff, professional bodies, such as theRoyal College of Nursing and nurse colleagues.

Participants were particularly concerned about theneed for support with professional development andupdating. Updating is a statutory requirement fornurses and is essential in the maintenance of clinicalcompetence, but there is a lack of a formal system forupdating. NP2 recalled No. I havent had a prescribingupdate. Even trying to get an update on how to use

your British National Formulary, any new drugs, is dif-ficult. However, at one site, they had been proactive:weve tried to set up a little forum for the nurses oncea month, where we can go through issues and wecheck on the new guidelines. We go on the website tofind out what new drugs are out, the side effects, etc.

Discussion

The study sought to extend the current literature by us-ing a sample of experienced NPs working in generalpractice who were interviewed in depth about changes

in their job since they qualified as independent pre-scribers. The study is limited in so far as the sample sizewas relatively small and confined to one city. Neverthe-less, the quality of the data is rich and robust enough towarrant the findings being reported. Moreover, wewould suggest that the findings have implications forpractice and policy makers.

The findings from this research are in agreement withearlier studies and add clarity to the picture. ExperiencedNPs made an overall evaluation that becoming a pre-scriber had increased their job satisfaction; however, notall aspects of the job were better. The participants in thisstudy were all positive about prescribing and stated that

the benefits were such that they would not be preparedto go back to working in a non-prescribing clinical role.Satisfaction resulted from the new ability to completecare autonomously and holistically, alongside an increasein respect from patients and some colleagues; the increasein work-related stress arose from perceived work over-load, pressure to prescribe and a lack of support towardsprofessional development. Lack of remuneration for theincreased clinical responsibility also led to a perceivedsense of unfairness.

The effortreward imbalance model21 purports thatwhere work demands are high but are matched by a highlevels of job control and reward and then individualsperceive a sense of satisfaction and work is experiencedas a positive activity. The themes emerging from the in-terview data support Siegrists model, and additionallysuggest that although NPs, who were also independentprescribers, hadperceptions of effortreward imbalance,while stressful,22 these were not sufficient to outshinethe increased satisfaction experienced in the vocationalaspects of the job-increased autonomy and holistic pa-tient care. Nevertheless, this is a matter for concern forgeneral practices, in terms of efficacy and duty of carefor employees.

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In conclusion, this sample of NPs judged that over-all, there was an increase in their job satisfaction sincebecoming an independent prescriber, in line withCrowns assertion.1 This, however, has to be temperedby increased potentials for work-related stress. If num-bers of nurse prescribers are to be increased in generalpractice, which remains a government objective, then

potential stressors need to be managed. Given the cur-rent economic situation in the UK, nurse-independentprescribing is unlikely to be upgraded; nevertheless,there are benefits for nurses becoming independentprescribers and these need to be highlighted. Manag-ers should also be clear that no additional remunera-tion is guaranteed, and similarly that role descriptionsare clear. Additionally, nurse prescribers should be in-cluded in relevant practice management meetings andfully supported in terms of continuing professionaldevelopment.

DeclarationFunding: The authors confirm that no funding wasreceived to support this study.Ethical approval: Liverpool Hope University ResearchEthics Board.Conflict of interest: none.

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