1. Introduction
In situations in which the demand for healthcare services exceeds the number of physicians available, nurse prescribing is normally recommended. This is because it has been found that the prescribing behavior of the nurses is equal to that of the physicians. The context within which nurse prescribing takes place exerts an influence on the mode of prescribing. In order to understand the views of nurses and other team members on nurse prescribing diabetes services, a case study was carried out in nine sites in England in order to determine the context within which nurses prescribe medicine for patients who are diabetic. An analysis of the emergent themes drawn from 31 semi structured interviews that were conducted in the period between 2007 and 2008 was carried out. This essay shall focus on the s critique the aforementioned study using the Critical Appraisal Skills Programme critique tool. The following aspects of the article shall be critiqued: the statement of the aims, the methodology, the research design, the recruitment strategy used in recruiting the participants in the study, the data collection and data analysis methods, the validity of the results and the ethical issues.
2. Evidence based nursing practice
According to the a survey that was conducted in the United Kingdom in 2007, 60% of diabetes specialist nurses are involved in prescribing medicines to patients with diabetes while another 90% work independently at clinics that offer services to patients with specialists needs. Nurse Independent Prescribing entails the independent diagnosis, assessment and prescription of the full range of drugs in the British National Formulary being carried out by the nurse. Nurse Supplementary Prescribing entails team work between the physician and the nurse in which the physician carries out the assessment and the diagnosis then comes up with a clinical management plan from which the nurse must write the prescription. The legal framework that supports nurse prescribing has evolved over the recent years in the United Kingdom therefore giving rise to an increase in nurse prescribing in the UK.
In spite the incorporation of nurse prescribing in different health care facilities, there are challenges that have arisen in the course of the execution of nurse prescribing. Some of the barriers that have been cited in relation to nurse supplementary prescribing include: lack of proper knowledge and skill, objections or restrictions by the employers and lack of access to medical records or inability to generate medical prescriptions . in relation to NIP, the most commonly reported problem was the lack of proper knowledge on clinical prescriptions, lack of support from the physicians and the pharmacists, restrictions by employers and practical problems .
- Critique of the journal article
The goal of the research was to draw out the views of nurses and team members on the implementation of nurse prescribing in diabetes services. This is important because there has been an increased campaign in the United Kingdom to enhance the services that are provided to diabetic patients. It is therefore critical to understand the perceptions of the nurses on the implementation of nurse prescribing in offering medical services to diabetic patients.
During the study, a total of nine sites were selected on purpose in order to draw out the views of the nurses who prescribe medication to patients with diabetes. According to the researchers, this was done in order to enable them to carry out a detailed study of nurse prescribing to diabetes patients. I believe that the small number of study sites could have a negative effect on the study in the following ways: To begin with, variation might have been highly limited. The limited number of sites could also contribute to an increase in the number of confounding factors. For instance, based on the proximity of the study sites to one another, it is possible that the nurses often interact hence influence each other’s views on prescribing. Therefore it is not possible to determine whether the views expressed by the nurses at each site are independent.
Six of the case sites were in general practice, two were based in hospital and two were community clinics. The sites of the study were located in a mixture of urban and rural areas. The study sites were purposively selected; an aspect that would contribute to meeting the main objective of the study. In addition to this, it is easier to identify sites that practice nurse prescribers as compared random sampling. Time is therefore saved and dedicated towards meeting the objective of the study. On the other hand, purposive sampling prevents the researcher from making inferential deductions from their results. It therefore prevents the researcher from using inferences based on statistical calculations that can be used to gauge the accuracy of the results.
The researchers carried out 31 semi structured interviews that were conducted at mutually convenient times and locations at the sites of the study. The semi structured interviews were developed on the basis of works that had been conducted previously and literature review. In basing the interviews on previous work, the researchers were able to review arguments that had been advanced in the past, the methodologies used and the results of the studies. For instance, previous works show that the prevalence of nurse prescribing in the United Kingdom is as follows: 74% of nurse prescribing was found to be within general practice, 14% was found to be in hospitals or community clinics while 6% of nurse prescribing was found to take place in diabetic centers. Based on these results, the researcher came up with the distribution of the study sites which was as follows: six sites were in general practice while four were community clinics and hospitals respectively. The design was therefore a reflection of evidence based practice hence relevant to the practice setting.
The data from the case study was collected in the period between October 2007 and September 2008. The researcher clearly outlines the method of data collection which was semi structured interviews. The interview covered the following aspects: the difficulties experienced by the nurses in implementing nurse prescribing, changes or alterations to the work schedule as a result of prescribing and the views of the nurses who wrote prescriptions for diabetic patients. The scope of the interviews demonstrates the researchers’ commitment of the researcher towards meeting the objectives of the research. The interviews are also structure in line with the literature that had been conducted by researcher. Interviews allow for the researcher to collect first hand information from the nurses hence enhancing the accuracy and the validity of the data that was collected. The interviews also allow the researcher to make observations and come with secondary questions that can later form the basis of further research. In spite the benefits of interviews, there are also demerits associated with the interviews: interviews are very time consuming hence the long period of time taken to conduct the study in spite the small number of study sites and participants. The researcher however does not outline his reasons for opting for interviews as his method of data collection or the criterion for opting for interviews over other methods of data collection. In so doing, it is not clear whether the interviews were chosen because they were the best method or simply because of the researchers’ own preferences.
The nurse prescribers who participated in the study were purposively selected from the respondents of a questionnaire for a previously conducted survey. purposive selection of the participants provided the researchers with an opportunity to carry out his research in phases and draw upon previous works as the basis for his research. The researcher in this case drew upon the survey that had been conducted by Courtenay & Carey in 2008 in the selection of the respondents to the interviews. However, the downside of the purposive selection of the participants was that it is prone to the subjective and judgemental biases of the researchers. This implies that theoritical basis is often subject to ill conceived theories or judgements that have been poorly considered.
In order to eliminate any biases that may have arisen in the course of the interviews, the researchers subjected a selection of the interviews to independent reviews by two qualitative researchers who were experienced. The results were further validated by members of the Diabetees Prescribing network meeting. In doing so, I believe the researcher ensured that the results were a reflection of what is actually practiced and was in accordance with the recommended practices. This lends credibility to the case study.
During the case study, approval was obtained from the National Health Services and the university ethics committee. The researcher however does not give a detailed account of the ethical policy of the university or the ethical considerations of the National Health Services. It is therefore not clear whether the researcher fully observed ethical stipulations in the course of the study. It is also not clear whether there were instances in which participants may have declined to participate on account of ethical considerations such as confidentiality.
An analysis of the themes was carried out which entailed familiarization with the data, coding, sorting of the data into categories, identification of emerging patterns and finally the interpretation of these patterns. The researchers were keen on drawing out the themes that are related to nurse prescribing hence compared the findings with those of other studies. While this was an advantage, it may also have been a source of bias since the researchers may have been inclined to have findings that are reflective of findings from previous studies.
There was a clear relationship between the themes that were discussed and the findings of the study. This was evident from direct quotations from the participants which were indicated by a code referring to case site and group from which the participant was drawn. It was therefore possible to distinguish between the different participants which included physicians, administrative staff, non nurse prescribers, nurse prescribers. According to the nurses who participated in the study, they had increased their prescribing activity following the expansion of the rights of nurses to prescribe in 2006. Prior to 2006, the nurses had done supplementary prescribing of oral hypoglycaemic agents and insulin due to the restrictions imposed by the formulary. This is evident from the quotations included of a nurse who could not prescribe due to restrictions in spite being qualified. The researcher also takes into account the views expressed by nurses who do not give prescriptions by citing their reasons for not doing so which included: time requirements, the complexity of diabetes and practical and organizational problems in administration of clinical management plans.
The findings of the study are explicitly presented by the researcher. The researchers discuss the emerging themes against the backdrop of the quotations drawn from the participants in the study. The researchers were presented evidence that not only support the findings of the study with data that corroborated the findings but also goes against the findings of the study. With the extension of the rights of the nurses to prescribe, it was expected that nurse supplementary prescribing would be more prevalent. However, the findings of the study indicated that nurse supplementary prescribing was less prevalent than expected. This is in spite the fact that past research had shown that 48% of the nurses had used NSP at some point. The present case study revealed that NIP was the preferred option for the nurses.
The data from the case study revealed that the support offered to the nurses was critical in the implementation of nurse prescribing in diabetes services. It was found that nurses made use of the support they got from their peers in order to build confidence in their prescribing role. The support offered by physicians in terms of continuous training and supervision is critical in nurse prescribing, .
The research findings show that the discontinuation of the formulary restrictions contributed to an advancement of nurse prescription; an aspect that enhances the role of nurses in improving provision of health services to diabetics. The design of the study allowed for analytical transferability but not statistical generalization. This is because the findings are only reflective of the views of nurses and the colleagues that they work with but not the necessarily the rest of the health professionals.
References
Avery, A., & M.Pringle. (2005). Extended Prescribing by Uk nurses and pharmacists. BMJ , 1154-1155.
Bergen, A., & While, A. (2000). A case for case studies: exploring the use of study design in community nursing research. Journal of Advanced Nursing , 926-934.
Braan, V., & Clark, V. (2006). Using thematic analysis in psychology. Qualitative research , 77-101.
Bradle, E., & Nolan, P. (2007 ). Impact of nurse prescribing: a qualitative study . Journal of Advanced Nursing , 120-128 .
C.Pope, Zeibland, S., & Mays, N. (2006 ). Analysing qualitative data . Oxford: Blackwell .
Carey, N., & Courtenay, M. (2007a). A review of activity and effects of nurse led care in diabetes . Journal of Clinical Nursing 16 , 296-304.
Cipher, D., & Guetra, P. (2006 ). Prescribing trends by nurse practioners and physician assistants in the United States . Journal of the American Academy of Nurse Practioners , 291-296.
Courtenay, M., & Carey, N. (2008c). The prescribing practices of nurse independent prescribers caring for patients with diabetes: finidings from a national questionnaire survey. Practical Diabetes international , 1-5.
Courtenay, M., Carey, N., & Burkey, J. (2007 ). Independent extended and supplementary nurse prescribing practice in the UK: a national questionnaire study. International Journal of Nursing Studies 44 , 1093-1101.
Critical Appraisal Skills Programme. (2010, October 14 ). Retrieved November 27, 2012, from Casp UK : http://www.casp-uk.net/wpcontent/uploads/2011/11/CASP_Qualitative_Appraisal_Checklist_14oct10.pdf
Hall, J., Cantrill, J., & Noyce, P. (2006 ). Why don't trained community nurses prescribe. Journal of clinical nursing , 403-412.
Miles, K., & Oseito, M. (2006). Nurse prescribing in low resource settings: proffessioal considerations . international Nursing review , 290-296.
Otway, C. (2002 ). The developing needs of nurse prescribing . Nursing Standards , 33-38.
Roberts, S. (2007 ). Working together for better diabetes care. London: Department of health .
Stake, R. (1995). The Art of Case Study Research: Perspectives on research . London: Sage.
Stenner, K., Carey, N., & Courtenay, M. (2009 ). Implementing nurse prescribing: a case study in diabetes . Journal of Advanced Nursing , 522-531.
Wears, R. (2002). Advanced statistics: statistical methods for analyzing cluster and cluster-randomized data. Academic Emergency Medicine , 330-341.
Yin, R. (1994). Case study research design methods. London : Sage.
