The impact of nurse prescribing on health care delivery for patients with diabetes: a rapid review

Search strategy

The rapid review approach is a modified form of the systematic review method. By limiting literature searches or simplifying the process of systematic reviews, rapid reviews ensure the timely generation of information while upholding ‘systematic, transparent and reproducible’ standards.^16,17 The protocol for this rapid review has been lodged with PROSPERO.¹⁸ Between 2 and 30 November 2022, a search for relevant literature/resources (by KS) was completed across PubMed, CINAHL, Scopus, and MEDLINE; the ProQuest Dissertation and Thesis database; and the Cochrane Library of Clinical Trials. Grey literature was also searched, including ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry, and the World Health Organization database of clinical trials.

A restriction to publications within the last decade (between January 2012 and November 2022) was applied. This timeframe was chosen due to the limited literature available in the last 5 years. The following search terms were used across all databases (subject to any individual platform requirements): all related terms to non-medical prescribing with a focus on nursing (nurs* prescrib* AND nurse practitioner) OR (non-medical prescrib*) AND (diabet* OR diabetes). A forward and backward citation review was completed for all articles that met the inclusion criteria. From there, any further literature identified as meeting inclusion criteria was included.

Study selection

A set of open selection criteria allowing case reports, case-controlled studies, cohort studies, cross-sectional studies, prevalence studies, quasi-experimental, random control trials, qualitative research, mixed methods research, literature reviews/research syntheses, and text/opinion pieces were used. The condition for inclusion was that the publication referenced the prescribing practice of nurses and nurse prescribing in diabetes, encompassing both NP and RN prescribers. The detailed inclusion and exclusion criteria are shown in Table 1. Endnote was used to manage and code extracted data.¹⁹

Data extraction

Potential literature for inclusion was identified by reviewing article titles. Subsequently, abstracts were screened for articles that met the inclusion criteria. Next, the full text of relevant resources was examined to determine eligibility for inclusion. Any uncertainties regarding publication suitability were resolved through discussions among the review team. A consistent template was used for recording extracted data, encompassing aims, design methods, setting, participant demographics, outcomes, appraisal tools for assessing resource quality, and suitability for inclusion in the rapid review. Each team member independently reviewed 10% of the data to ensure inclusion consistency.

Quality appraisal

A quality assessment was completed for each publication meeting the rapid review inclusion criteria. Joanna Briggs Institute’s Critical Appraisal Tools²⁰ were used to evaluate the quality of qualitative and quantitative studies, literature reviews, and narrative publications. The Mixed Methods Appraisal Tool Version 2018²¹ was used for appropriate studies. Studies not meeting quality criteria were excluded from the review.

Ethics

There were no human subjects involved, as this was a rapid review.

Clinical outcomes through the inclusion of nurse prescribing

Seven of the articles addressed the clinical outcomes associated with nurse prescribing. Courtenay et al.’s²² case study based in the UK aimed to compare nurse prescribers and non-prescribing nurses in relation to the processes, outcomes, and cost of care for people with diabetes. Clinical outcomes for patients managed by nurse prescribers or nurses without a prescribing role were similar. No significant statistical differences were observed in patients’ initial and subsequent changes in raw scores for HbA1c and body mass index or self-management behaviours. Patients cared for by both groups were reported to have a significantly decreased HbA1c.

Further to this, Tabesh et al. conducted a systematic review and meta-analysis to explore the clinical outcomes of HbA1c for patients with diabetes attending nurse-led clinics where nurses were involved in prescribing.²⁹ This work explored the clinical outcomes for patients where the nurse prescriber was a supplementary member of the health care team versus when the nurse prescriber was working in an independent role. The findings indicated no clear benefit to glycaemic control when the nurse prescribed alongside the doctor. However, when nurses prescribed independently, the patients of both the nurse prescribers and medical prescribers achieved comparable improvements in HbA1c results.

The comparable clinical outcomes of HbA1c levels for patients with diabetes were also reported in other studies.^30,31 Through a meta-analysis of 46 studies, Weeks et al. examined the clinical outcomes of non-medical prescribing in acute and chronic disease management in primary and secondary care.³¹ Findings indicated a high certainty of evidence to support comparative glycated haemoglobin levels at 12 months between groups receiving non-medical and medical prescribing interventions. Wang et al.’s meta-analysis of 17 randomised control trials also evaluated the impact of nurse-led clinics and nurse-led prescriptions on HbA1c control in type 2 diabetes (with a combined sample size of 2701 patients).³⁰ Their findings also indicated that the clinical outcomes of HbA1c from the nurse-led prescribing group were comparable to those of the medical practitioners.

Level of satisfaction

Seven articles explored the level of satisfaction associated with nurse prescribing services.^{9,12,22,27,32,33,35} Satisfaction encompasses the patient, nurse, and service perspectives. In Courtenay et al.’s study,²² patients reported a high level of satisfaction with all nurses about their levels of medication knowledge. However, nurse prescribers received higher patient satisfaction ratings for previous symptom knowledge, treatment confidence, practical advice, and coping support. A similarly high level of patient satisfaction with nurse prescribers was reported by Wilkinson et al.¹² in their multi-method study. Patients noted comprehensive consultations and proactive management plans in nurse-led care. Across several studies, patients consistently viewed nurse prescribing as safe and acceptable.^9,32

Akin to patient satisfaction levels, studies also noted job satisfaction for nurses who were able to prescribe.^27,33 Wilkinson’s²⁷ study evaluated the perceptions and intentions of experienced nurses working in NZ’s primary health care about the two proposed levels of RN prescribing practice (specialist and community). Prescribing was seen as an extension of the nurse’s scope of practice that would overcome the limitations of working under standing orders, increasing job satisfaction, autonomy, and accountability. Diggle also highlighted job satisfaction through independence and nurse autonomy.³³ Moreover, fellow professionals in the multidisciplinary team, including physicians, GPs, and other medical staff, expressed satisfaction, often due to fewer interruptions for doctors when nurse prescribers worked more independently.¹²

Implications for service provision

The implication for the provision of services was a central theme evident across 12 of the studies.^{9,12,22–28,32,33,35} Several studies indicated that nurse prescribing may have met the unmet needs of minority populations.^24,25,27 Poot et al.’s retrospective observational study explored nurse prescribing patterns in NZ, revealing that NPs prescribed a wide range of medications, primarily serving patients with greater health needs in areas of high deprivation, including Māori populations.²⁴ While the results suggested that NPs interacted with a higher percentage of Māori, a lower percentage of Pasifika patients were seen. Snell et al. reported similar findings, noting that NZ nurses prescribed more frequently to minority groups (Māori, Pasifika, and Asian) due to their higher risk status in diabetes. In contrast, UK nurses primarily prescribed to a predominantly white ethnicity, which mirrors the demographic composition of the UK reported in the 2011 national census as 86% white.²⁵

Improved access to medications for patients was another key service provision that was frequently reported in the literature. A historical review exploring the development of the interprofessional diabetes workforce concluded that a key evolution in the provision of diabetes care could be attributed to the introduction of non-medical prescribing.²⁸ In the study by Wilkinson,²⁷ most respondents – experienced nurses working in primary health care settings – saw the proposed RN prescribing practices as a pathway to addressing issues such as poor availability of doctors, the cost of doctor visits, and transport difficulties, thereby improving access to medications for high-needs populations. Courtenay et al.²² also reported that being able to prescribe allows nurses to work more independently and permits more patient reviews across the multidisciplinary team, despite an increased cost to the employer when having nurse prescribers as part of the team.

A survey of 92 members of the DNS Section of the NZ Nurses Organisation aimed to gather data supporting workforce planning.²⁶ Results of the survey indicated that participants agreed with the findings from Courtenay et al.²² and suggested that having nurse prescribers increased patients’ timely access to diabetes medications. Wilkinson et al.¹² found that nurse prescribing resulted in more in-depth consultations, adding to patients’ education and understanding of the medications. Further publications support that enhanced access results in improved patient outcomes by ensuring timely treatment.^33,35

Barriers and facilitators to the role of nurse prescribing

Factors that act as barriers and facilitators to the nurse prescribing role were also identified as impacting service provisions for patients with diabetes. Snell et al. reported that there is consensus that inadequate time for quality mentoring was a barrier to these nurses working at this level; other barriers included poor organisational prescribing policies and limited access to ongoing professional development.²⁵ In addition, a lack of formal and continuing clinical supervision was also reported as a barrier to sustainable nurse prescribing.^12,26 As Snell et al. concluded, factors including good supervision, positive collegial relationships with specialist medical staff, pharmacists, and nursing peers, and access to ongoing education would positively influence the nurses’ prescribing role and facilitate their ability to work at the top of their scope of practice.²⁵ The positive influence of strong educational pathways and academic preparation for nurse prescribing practice was also expressed.^26,27

Strengths and limitations

This review benefits from a structured search process backed by a PROSPERO protocol and a robust appraisal strategy. While the inclusion criteria focused on NZ, Australian, the UK, and Canadian literature, global context was provided through several multi-country systematic reviews. One limitation is the 10-year timeframe, excluding older articles that could have enriched the discussion. However, this timeframe aligns with the recent introduction of nurse prescribing in NZ, making it more locally relevant. In the context of a rapid review, the search spanned multiple databases and grey literature sources, offering a comprehensive data overview. Although not all literature underwent double screening, the inclusion of a moderation process bolstered the findings. The international variation in NP and RN prescribing practices represents a limitation of this rapid review, as it encompasses publications from various countries, each with its distinct regulatory frameworks and scopes of practice, potentially impacting the generalisability of findings.

Recommendations for practice and research

The review underscores the need for ongoing support and mentoring, especially for RN prescribers, both during the learning process and beyond. Establishing a culture of mentorship for all health care professionals, while not strictly mandated beyond registration for authorised prescribers, would be mutually advantageous for the multidisciplinary team, significantly benefiting RN prescribers and enhancing patient care. Nurse prescribing potentially enhances access to care and alleviates the health care system’s burden. Future research should prioritise investigating clinical outcomes for diabetes patients under nurse prescribing, assess the influence of nurse prescribers on treatment compliance and management, and explore nurse prescribing’s impact on health care service delivery in the NZ context.