Table 6.
Three-step approach to metasynthesis
| First-order interpretations | Second-order interpretations | Papers | Third-order interpretations |
|---|---|---|---|
| Efficiency, timeliness, waiting times, access to medicines, reduced hospital admissions, use of skills, confidence in NMP, more time with patient, acceptability, patient satisfaction, ability to provide information, patient choice, improved adherence, flexibility in appointment times, concordance, minimal disruption, lack of established relationship made nurses uneasy about prescribing, patients expected more than nurses could offer | Patient impact | 1, 5, 8, 10, 13, 14, 15, 17, 20, 21, 24, 27, 35 | The need to provide patient-centred care |
| Seamless care, improved patient care, better patient care, complete episodes of care, patient-centred, continuity of care | Completing care | 1, 2, 5, 8, 10, 12, 15, 24, 30, 35 | |
| Effectiveness of treatment, cost-effectiveness, resources, nurses felt they were more aware of budgetary issues, whereas doctors worried they would not be aware. External pressures from their managers and formularies to prescribe low-cost products, more time for consultations, value to the service | Service impact | 1, 2, 10, 13, 17, 20, 24 | The benefits to the service |
| Training, preparation for practice, assimilation of knowledge, correlation between specialist training and higher rates of prescribing, knowledgeable about pharmacology, more knowledgeable, CPD, responsibility to keep up to date | Knowledge | 2, 4, 6, 7, 9, 10, 11, 12, 14, 15, 17, 19, 21, 22, 25, 30, 31, 35, 37 | The need for knowledge |
| Accountability, use of guidelines, those who did deviate tended to be more experienced NPs. Views on formularies were neutral (a guide) to negative (restrictive) | Accountability | 2, 3, 17, 33 | Professional accountability and boundary setting |
| Confidence, comfort, familiar products, competence to diagnose, decision-making, risk of becoming over confident, over-estimation of competence, increased anxiety with increased responsibility, less comfortable prescribing items for first time or that they rarely prescribed, more comfortable prescribing items associated with low risk), some products risky (paracetamol and laxatives), less comfortable prescribing for the first time or an item rarely prescribed | Competence | 2, 3, 4, 8, 10, 12, 15, 17, 20, 25, 26, 31, 35 | |
| Risk taking, safe and unsafe items, safer than by proxy, more careful, audit, co-morbidities, concerns re-lack of diagnostic expertise, cautious approach supported patient safety, range of quality assurance tools and CPD activities used, lack of experience in prescribing for particular age groups, lack of access to records to determine underlying conditions, allergies, if treatment had been prescribed previously, more comfortable prescribing items pts have had before, uncomfortable prescribing for a pt they did not know, fear of making mistakes, reliability of patient and caregiver | Avoiding harm | 2, 3, 4, 8, 10, 12, 14, 17, 20, 22, 26, 30, 32, 35 | Safety consciousness |
| Chore of repeat prescribing, pressure to prescribe, differences in practice, time, lack of support and CPD, cross-GP boundary challenges, budgets, increased workloads, lack of reward, legal limitations, executive factors, educational deficiencies, research weaknesses, concerns re-pharmacological knowledge, lack of understanding of role, limited formulary, access to records, views on formularies ranged from neutral to negative, with them acting as a guide which was not required or restricting prescriber choice/professional freedom | Barriers | 2, 3, 7, 8, 10, 11, 12, 13, 15, 17, 18, 26 | Barriers to effective prescribing |
| Job satisfaction, improved professional role, being left behind, self-empowerment, professionalism, working outside traditional boundaries, complement not replace doctors, new boundaries, traditional hierarchies, doctor-checking, exclusive to doctors, self-esteem, ability to challenge, legitimising nursing role, integrating caring and curing, medicalisation, add-on role, brand of prescriber, autonomy, status, respect from colleagues and patients, essential to specialist roles, shared territory, reaching full potential, increased the respect they received from doctors, used prescribing to complement nursing actions rather than substitute other aspects of their role, job descriptions should support the NP role | Nursing role | 2, 3, 5, 6, 8, 9, 10, 11, 12, 13, 14, 26, 27, 29, 30, 33, 35, 36 | Role preservation |
| Improved relationship with pharmacist, collaborative working, improved communication with colleagues, doctors’ time was also used more effectively to deal with more complex cases, some doctors unclear about nurses prescribing authority, good interdisciplinary communication re prescribing in their area of practice, GPs dictating what can be prescribed, access to GPs, control and domination, inappropriate expectations, lack of understanding of role, fear of exploitation, resistance from colleagues, professional rivalry, no change in status, change in content of conversations and in team interactions, lack of reward | Collaboration and relationships with colleagues | 2, 3, 4, 9, 10, 12, 14, 16, 17, 24, 33, 34, 36 | Power-shifts in inter-professional relationships |
| Support, trust, link between support of doctor and effectiveness | Doctor’s influence and support | 3, 4, 5, 8, 9, 10, 25, 28, 34, 36, 37 | |
| Need for organisational support, fragmented implementation of policy, NP was largely driven by the practitioner to enhance existing services rather than enable service re-design, only half of Trusts had a strategy for the development of NMP, organisational preparedness | Organisational support | 1, 3, 5, 10, 14, 22, 34, 36, 37 | Culture of prescribing |
NMP=non-medical prescribing; CPD=continuing professional development; NP = nurse prescribers