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Family Practice 2012; 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: cousinr@hope.ac.uk
Received 1 March 2011; Revised 31 July 2011; Accepted 22 August 2011.
Background. Studies examining the impact nurse prescribing have largely focused on the ef-
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 interviewdata 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 insufcient
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 1992
was underpinned by recommendations of the Depart-
ment of Health advisory group report;
1
known as the rst
Crown Report, it included various supportive clinical ar-
guments and additionally asserted there would be an in-
crease in job satisfaction for nurses. Job satisfaction is
old construct that has stood the test of time. It is a combi-
nation of psychological, physiological and environmental
circumstances that cause a person to assert that they are
satised with their job.
2
It assesses the difference be-
tween an individuals expectations, and what he or she
actually experiences. Such a denition indicates a variety
of variables that inuence 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.
46
How-
ever, extant studies have largely focused on the
positives, without due consideration of any negative
aspects, 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 for
stress in general practice have also been documented.
9
It is estimated that 14 000 nurses now have almost
the same prescribing rights as doctors in the UK,
10
al-
though the number of nurse-independent prescribers
in general practice has not reached predicted levels.
11
A recent survey in one English county indicated that
<20% of practice nurses managing chronic conditions
held a nurse prescribing qualication
11
despite evi-
dence that many GPs are positive about nurse pre-
scribing, and patients are both satised and condent
223

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in being treated by a nurse prescriber.
1214
There are
no studies that are specic to nurse prescribing in gen-
eral practice to explain the relatively low numbers of
nurse practitioners (NPs) who are also independent
prescribers.
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 conrming Crowns
assertion that independent prescribing increased job
satisfaction, we additionally explored whether the ex-
tended role made a difference to potentials for stress
in NPs.
Methods
Design
A qualitative approach was chosen. This was most ap-
propriate towards teasing out the longitudinal element
of the research. In-depth semi-structured interviews
were used to collect rich data describing the context,
perceptions, actions and emotions of participants
in relation to job satisfactions and dissatisfactions in
relation to nurse prescribing in general practice.
Sampling
Six NPs who were also experienced independent pre-
scribers were interviewed (ve females and one male;
aged 3648 years). All had held the qualication 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 qualication V300independent
and 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. Full
clinics and issuing several computer-generated prescrip-
tions during each clinic was the norm. All the practice
clinics operate during the hours 8:3018:30 under
a booking system; additionally, the one site purposely
serving the large student community in the city has
a walk-in clinic during the hours 8:3016:00 during
term-time. While the sample size is small, it is represen-
tative of the number of NPs meeting the criteria in the
city. This type of study often includes a small cohort.
15
Additionally, there is some conrmation of the suf-
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 hours
were undertaken with the NPs in their homes, at a time
of their convenience. The interviews explored the
changes 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/difculties
of being a prescriber? A digital voice recorder was
used to aid transcription, and additionally, contextual
notes were made by the interviewer. The data were
fully 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 of
two or more independent coders.
17
In this study, tran-
scripts of the six interviews were rst coded in full by
the authors and then another independent experi-
enced researcher agreed to read all six transcripts
and code the data (Consent was obtained from all
participants prior to sharing the data.). Holstis for-
mula 2m/N1 + N2
18
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 eld
notes and the interviewers judgement.
Results
Four themes were identied from the interview data:
benets of nurse prescribing, which had three subthe-
mesincreased control, greater autonomy and more
holism in role; increased job demands, support issues
and lack of reward. Further reduction of the data
produced two overarching concepts: increased job
satisfaction and work-related stress.
Benets of nurse prescribing
Autonomous practice was found to be pivotal to the
enhanced job satisfaction reported by all six NPs who
were also independent prescribers Figure 1. Being able
to complete an episode of care for the patient, which
previously would not have been possible if a prescrip-
tion was required, was key. Before becoming qualied
independent prescribers, at the very least, the NPs
would have had to have a GP sign off even routine re-
peat prescriptions. NP2 stated Its just that it makes
my 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
Family PracticeThe International Journal for Research in Primary Care 224

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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 I
can nish the whole consultation; because I dont have
to wait for other people to nish the care and I think I
give the best service to the patient. NP3 suggested that
a 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 and
get your prescription signed.
The NPs were all positive about the prescribing
role, perceiving it as enabling them to provide a more
holistic and complete type of care. For example, NP1,
a sexual health expert, said I get more job satisfaction
now because I can instigate treatment or rst pills. If
the patient is coming for the pill, I can prescribe it
and see them again. It has given me more autonomy.
The narratives strongly suggest that independent pre-
scribing increases NPs condence and self-esteem, which
in turn increases their job satisfaction. All six participants
claried that they prescribed only within their own com-
petencies, not stepping outside of them despite pressure
to do so from both patients and GPs. Prescribing within
ones competencies ensures safe prescribing and also en-
sures that practice is in line with current NMC guidelines
contained within the NMC Code of Professional Con-
duct.
19
This is important within any sphere of clinical
practice; however, it is of particular importance to NPs
as independent prescribing is a relatively new role for
them. 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 able
to professionally delineate their competencies for pre-
scribing increased condence as NPs became more expe-
rienced, which in turn increased job satisfaction, and for
some participants an expressed increase in self-esteem.
There was consensus among the NPs that they could
not go back to a non-prescribing role. Considering be-
fore becoming a prescriber and her current position
NP3 said I couldnt stand outside a GPs door after
doing all the training. Id be offended that I couldnt
use it. It would downgrade the whole role and I think
nurse prescribing gives you some kudos. And as NP5
observed, the patients are aware of your skills and
they know youre making decisions and prescribing
for them. It gives you a sense of satisfaction.
Autonomy, holism and increased job control were rec-
ognized as advantages of the independent prescribing
role by all six NPs, with nurse prescribing in turn leading
to a perceived increase in patient satisfaction, which was
also important to all the participants. Increased job con-
trol was highlighted many times in conjunction with the
provision 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 episode
of care and the absence of the need for medical input. As
NP6 noted with approval, I dont have to wait outside
doctors doors anymore. I think it validates independent
thinking.
The main advantages arising from the prescribing role
appear to be an overall increase in job satisfaction, which
results from the ability to complete care autonomously
and holistically. This involves a high amount of job con-
trol, with nurses assessing, diagnosing and treating inde-
pendently. Other factors contributing to increased job
satisfaction are the enhanced status enjoyed by nurse
prescribers and the increase in self-esteem, which arises
from patient recognition of the nurses enhanced skills
and respect from colleagues.
Lack of rewards
The increased intrinsic rewards described above, were
not, however, supplemented by increased extrinsic re-
wards. All six participants claried that NPs who go on
to qualify as independent prescribers do not move up
to a higher grade and are not rewarded nancially. Par-
ticipants felt aggrieved that the effort of attaining the
qualication and the increased responsibility associated
with independent prescribing has not been recognized
by the UK Governments Agenda for Change docu-
mentation,
20
which outlines the pay, terms and condi-
tions for the National Health Service (NHS). The salary
banding for NPs does not include recognition for those
working in a prescribing role. As NP1 reported Im on
the same grade now as I was on four years ago and
didnt prescribe. This is going to be a difcult issue to re-
solve in the current climate of cuts in the NHS, but there
was the suggestion in this study that the lack of increased
grade and pay is a barrier to some NPs becoming inde-
pendent prescribers and is a factor in losing independent
prescribers in general practice to the profession.
The effortreward imbalance model
21
argues that
stress arises where there is a belief that the efforts in-
vested in a job are not appropriately rewarded, and
there was some evidence in support of this in the experi-
ence of interviewing and the narratives. Participants felt
under-rewarded as independent prescribers in general
practice. Critically, there were perceptions of a mismatch
of effort and reward, which is known to be related to
burnout, 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, the
need for more knowledge and the need to continually
update knowledge, perceived lack of sufcient consulta-
tion time to deal with the more complex needs of the
patients, increased responsibility associated with diag-
nosing and prescribing and the pressure to prescribe.
225 Nurse prescribing in general practice

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Time constraints were an issue for participants, with
the main problem being consultation time given to nurses
for appointments. In line with the recent call from the
Royal College of General Physicians for 1520 minute
appointments,
23
participants felt that in their specialty 10
minutes for an appointment was insufcientespecially
as this was the same time for a consultation as before they
were prescribing. Job control is decreased by the time
constraints and where job demands are perceived as ex-
cessive and not matched by reward, individuals can feel
undervalued and the imbalance between effort and re-
ward increases. This can result in individuals becoming
de-motivated, stressed and in some cases depressed.
21
Participants expressed feelings of frustration and
stress during interviews and some stated that they
were having difculty coping with their workload in
the allotted time. This was exacerbated by the pres-
sure to prescribe from both medical staff and patients.
Participants suggested that the expectations of GPs
and 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. NP5
argued I dont think all our colleagues are clear about
non-medical prescribing. Also, patient expectations
can cause problems. It can be hard to persuade them
that they dont actually need a prescription. This
causes pressure and takes up consultation time.
Pressure to prescribe was a major demand on all the
participants and the frequency of the occurrence of this
aspect of the job demand subtheme was much greater
than any other aspect. One nurse, felt this acutely, and
when asked by whom, stated by patients, by people in
the 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 an
anti-depressant which Im not going to prescribe. Thats
probably the biggest challenge. It was clear that misun-
derstandings around the nurse prescribing role has led
to patients being given inappropriate appointments by
receptionists, which in turn, angers patients and causes
more pressure for nurses. Nurses in this position need to
refer to practice colleagues and this lack of control, in
the face of high job demands is stressful.
All the participants conrmed that working as an in-
dependent prescriber affords a signicant increase in
clinical responsibility, and with experience, awareness
of the increase in clinical responsibility develops. The
extra responsibility combined with the pressure to pre-
scribe and lack of consultation time caused partici-
pants to feel stressed during busy clinics and support
was recognized as important.
Need for support
Perceived lack of support was an issue for all the par-
ticipants and several sources were identied, including
the medical staff, professional bodies, such as the
Royal College of Nursing and nurse colleagues.
Participants were particularly concerned about the
need for support with professional development and
updating. Updating is a statutory requirement for
nurses and is essential in the maintenance of clinical
competence, but there is a lack of a formal system for
updating. NP2 recalled No. I havent had a prescribing
update. Even trying to get an update on how to use
your British National Formulary, any new drugs, is dif-
cult. However, at one site, they had been proactive:
weve tried to set up a little forum for the nurses once
a month, where we can go through issues and we
check on the new guidelines. We go on the website to
nd 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 general
practice who were interviewed in depth about changes
in their job since they qualied as independent pre-
scribers. The study is limited in so far as the sample size
was relatively small and conned to one city. Neverthe-
less, the quality of the data is rich and robust enough to
warrant the ndings being reported. Moreover, we
would suggest that the ndings have implications for
practice and policy makers.
The ndings from this research are in agreement with
earlier studies and add clarity to the picture. Experienced
NPs made an overall evaluation that becoming a pre-
scriber had increased their job satisfaction; however, not
all aspects of the job were better. The participants in this
study were all positive about prescribing and stated that
the benets were such that they would not be prepared
to go back to working in a non-prescribing clinical role.
Satisfaction resulted from the new ability to complete
care autonomously and holistically, alongside an increase
in respect from patients and some colleagues; the increase
in work-related stress arose from perceived work over-
load, pressure to prescribe and a lack of support towards
professional development. Lack of remuneration for the
increased clinical responsibility also led to a perceived
sense of unfairness.
The effortreward imbalance model
21
purports that
where work demands are high but are matched by a high
levels of job control and reward and then individuals
perceive a sense of satisfaction and work is experienced
as a positive activity. The themes emerging from the in-
terview data support Siegrists model, and additionally
suggest that although NPs, who were also independent
prescribers, had perceptions of effortreward imbalance,
while stressful,
22
these were not sufcient to outshine
the increased satisfaction experienced in the vocational
aspects of the job-increased autonomy and holistic pa-
tient care. Nevertheless, this is a matter for concern for
general practices, in terms of efcacy and duty of care
for employees.
Family PracticeThe International Journal for Research in Primary Care 226

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In conclusion, this sample of NPs judged that over-
all, there was an increase in their job satisfaction since
becoming an independent prescriber, in line with
Crowns assertion.
1
This, however, has to be tempered
by increased potentials for work-related stress. If num-
bers of nurse prescribers are to be increased in general
practice, which remains a government objective, then
potential stressors need to be managed. Given the cur-
rent economic situation in the UK, nurse-independent
prescribing is unlikely to be upgraded; nevertheless,
there are benets for nurses becoming independent
prescribers and these need to be highlighted. Manag-
ers should also be clear that no additional remunera-
tion is guaranteed, and similarly that role descriptions
are clear. Additionally, nurse prescribers should be in-
cluded in relevant practice management meetings and
fully supported in terms of continuing professional
development.
Declaration
Funding: The authors conrm that no funding was
received to support this study.
Ethical approval: Liverpool Hope University Research
Ethics Board.
Conict of interest: none.
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227 Nurse prescribing in general practice

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