Introduction
The nursing profession in Poland is constantly developing. New solutions and competencies/authorisations for nurses are being implemented as a result of the need to meet patients’ expectations [1]. In line with the regulations concerning changes to the nursing and midwifery professions introduced in recent years, their powers have been extended to include, among other things, the ability to prescribe medicines independently, prescribe medical devices and refer patients for certain diagnostic tests. The increased authorisations aim to facilitate continuation of previous therapy, access to medicines and initiation of treatment without waiting to see a doctor [2]. In other countries such as the United States, the Netherlands, Ireland, Sweden and the United Kingdom, such provisions had already been introduced [3, 4].
The willingness of nurses to write prescriptions and continue supplying medications prescribed by a doctor in the context of the quality of services provided is an important element in the functioning of a healthcare facility. Many countries in the European Union make use of the possibility for nurses to prescribe medicines. The variation in these authorisations is related to the functioning of the healthcare system in a given country. Analysis in these regions indicates that the new competencies/authorisations for nurses benefit the whole system and, above all, patients. They have better access to medical consultations and medicines. Waiting times for prescriptions are reduced, it is possible to start treatment earlier and, in the case of chronic diseases, it is possible to continue treatment without the need for a doctor’s appointment. Studies confirm that nurses’ professional training and communication skills positively influence patients’ adherence to treatment, leading to higher satisfaction and better therapeutic outcomes [5].
The study aims to determine whether nurses’ ability to prescribe medications is perceived by patients, physicians, and nurses as improving the efficiency of healthcare services.
Material and methods
The study was carried out between May and September 2021 in 19 primary care facilities (3 public and 16 non-public) out of 23 facilities located in Kielce
(4 facilities did not consent to participate). Two facilities (1 public and 1 non-public) from each of the 13 districts of the Świętokrzyskie Province were also drawn to participate in the study. One of them did not agree to participate in the study. The selection was made using the R software (The R Project for Statistical Computing). In selecting the sample for the study, the sample size calculator was used from STATISTICA statistical software version for Windows 13.1 TIBCO Software Inc. – StatSoft. All nurses, doctors, and patients over the age of 60 who were present in the clinics during the survey were invited to participate.
Draft questionnaire
For the study, three survey questionnaires were constructed for nurses, doctors and patients, which underwent a validation procedure to confirm the reliability and relevance of the tool. The study was cross-sectional and was carried out using a diagnostic survey method. It involved 284 people, including 60 doctors, 81 nurses and 143 patients. The reliability of the test was assessed using Cronbach’s a coefficient (Table 1). High values of Cronbach’s a confirmed the reliability of the questionnaires. All questions and statements in the questionnaires were understandable to the subjects.
Study population
A total of 1077 people took part in the study, including 188 nurses, 266 doctors and 623 patients. Sociodemographic data of the study groups, such as gender, age, education, place of residence, place of provision of healthcare services and length of service are presented below.
The largest group of nurses (188; 100%) were in the age range of 40–49 years (60; 31.92%), living in cities (174; 92.55%) and with work experience of over 20 years (86; 45.74%) (Table 2).
Women (156; 58.65%) in the age range of 30–39 years
(83; 31.20%) and working in urban areas (251; 94.36%) were the largest group among the professional group of doctors (Table 3).
The largest group among the patients were men (321; 51.52%) in the age range of 60–69 years (385; 61.80%), city residents (445; 71.43%) and with a secondary education (305; 48.96%) (Table 4).
Statistical analysis
Logistic regression model was used to determine the predictors influencing the readiness of nurses and primary care facilities to write prescriptions and prescribe medicines and its correlation with the quality of healthcare services. The construction of the model was preceded by an initial selection of predictors by assessing their quality using Cramer’s V coefficient. At this stage, some of the predictors were discarded and the remainder were included in the sequential construction of the logistic regression model. For this purpose, forward stepwise regression was used and the significance of the difference between successive sequentially
built models was assessed using the likelihood ratio test. In the final step, another group of variables was discarded and found to be insignificant. The statistical significance of the predictors was verified using the Wald test. This was the procedure used to create three models for the study groups of patients, doctors and nurses. The good fit of the model was verified using the Hosmer-Lemeshow test (p > a was obtained for all three models, indicating a significant fit of the three logistic regression models obtained. In addition, a receiver operating characteristic (ROC) curve was constructed to verify if the responses of the patients, doctors and nurses derived from the model were consistent with the actual responses. The area under the graph of the ROC curve, denoted area under curve (AUC), measuring the good fit of the model, was calculated. A non-parametric c2 test of independence was used to determine the relationship between nurses’ preparation for prescribing medications and patients’, doctors’ and nurses’ assessment of the quality of medical care and resulting benefits.
Ethical considerations
The study was approved by the Bioethics Committee of the Collegium Medicum of Jan Kochanowski University in Kielce (Bioethics Committee Resolution No. 45/2020).
Results
The willingness of nurses to write prescriptions and continue supplying medications prescribed by a doctor in the context of quality of services provided is an important element in the functioning of a healthcare facility. The subjective opinion of the respondents regarding the prescribing of medicines by the professional group of nurses was found to be statistically significantly varied (p < 0.001). Patients believe that nurses are prepared to prescribe medicines themselves (412; 66.13%). Only one in five nurses (41; 21.81%) and one in three doctors (94; 35.34%) rated this competency as sufficient. The opinions of the patients, doctors and nurses surveyed regarding the competency of the professional group of nurses to continue supplying medications prescribed by a doctor were also found to be statistically significantly varied (p < 0.001). Patients (449; 72.07%) are the largest group who believe that nurses have adequate knowledge in this area. In contrast, one in three nurses (69; 36.70%) and one in three doctors (100; 37.59%) believe that nurses’ skills in this area are at a level that allows them to write prescriptions for medicines that were initially prescribed by a doctor. In the opinion of patients (476; 76.40%), the discussed solutions may determine an improvement in the quality of medical services, while nurses (37; 19.68%) and doctors (81; 30.45%) are not sure whether the new competencies/authorisations set out in the law will bring tangible benefits to the patient
(p < 0.001) (Table 5).
The respondents indicated the benefits of using the new nurse competencies/authorisations in terms of quality of care. Comparisons between the study variables were made using Pearson’s c2 test of independence. Opinions on the topic were found to be statistically significantly varied (p < a; a = 0.05). Patients believe that thanks to using the new nurse competencies/authorisations, the doctor will be able to spend more time with them (392; 62.92%) (p = 0.001), they will be able to get accurate information about their illness from the nurse (367; 58.91%) (p < 0.001), information on medication dosage (338; 62.28%) (p < 0.001) and waiting time to see the doctor will be reduced (430; 69.02%) (p < 0.001). A different view is held by the professional group of doctors, who believe that only they should provide patients with information about the disease (140; 52.63%) (p < 0.001) and medicine dosage (176; 66.17%) (p < 0.001). Nurses, like patients, believe that the new competencies/authorisations will enable the doctor to spend more time on consultations (104; 55.32%) (p = 0.001), reduce the waiting time for appointments (127; 67.55%) (p < 0.001) and provide accurate information on medicine dosage (124; 65.96%) (p < 0.001). The professional group of nurses said that patients would not get accurate information from them about their illness (103; 54.79%) and that the new developments would not contribute to faster access to medicines (188; 100%) (p < 0.001) (Table 6).
Predictors influencing the quality of healthcare services in terms of the new competencies/authorisations of the professional group of nurses were identified. The assessment of whether prescribing medicines will improve the quality of health services (the dependent variable in the logistic regression model) was defined as a dichotomous variable with two variants: it will improve the quality of services and it will not improve the quality of services. Based on the estimated logistic regression, prescribing medicines will improve the quality of healthcare services, in particular the patient receiving accurate information about the illness from the nurse (OR = 2.675; 95% CI: 1.793–3.992; p < 0.001) and faster access to medications (OR = 1.838; 95% CI: 1.229–2.748; p = 0.003). There is a decreased chance of improving the quality of medical services in the context of the new nurse competencies/authorisations when the patient is male (OR = 0.436; 95% CI: 0.291–0.654; p < 0.001). Patients believe that these solutions will not result in shorter waiting times to see a primary care doctor (OR = 0.622; 95% CI: 0.399–0.970; p = 0.031) (Table 7).
Based on the analysis of the area under the ROC curve, it can also be concluded that the model is a good fit to the data (AUC = 0.708) and has good predictive ability (Fig. 1).
A separate model was obtained for the predictors which, according to the professional group of doctors surveyed, influence the analysed area. Based on the estimated logistic regression, it can be concluded that, in the opinion of the physicians surveyed, prescribing medications will improve the quality of medical services, in particular the patient will have faster access to medications (OR = 6.522; 95% CI: 2.487–9.285; p < 0.001), obtain accurate information on medication dosage from the nurse (OR = 4.539; 95% CI: 1.748–11.791; p = 0.002) and have reduced waiting time to see a doctor (OR = 3.677; 95% CI: 1.041–12.981; p = 0.043) (Table 8).
Based on the analysis of the area under the ROC curve, it can also be concluded that the model is a good fit to the data (AUC = 0.934) and has good predictive ability (Fig. 2).
A third logistic regression model was obtained for the predictors which, according to the study group of professional nurses, influence the analysed area. Based on the estimated logistic regression, it can be concluded that, in the opinion of the nurses surveyed, prescribing medications will improve the quality of medical services, in particular the waiting times to see a doctor will be reduced (OR = 0.096; 95% CI: 0.038–0.242; p < 0.001), the patient will obtain accurate information on medication dosage from the nurse (OR = 0.386; 95% CI: 0.155–0.962; p = 0.041), while there is a decreased chance of getting accurate information about the illness from the nurse/the chance of getting accurate information about the illness from the nurse is reduced (OR = 3.944; 95% CI: 1.524–10.212; p = 0.005) (Table 9).
Based on the analysis of the area under the ROC curve, it can also be concluded that the model is a good fit to the data (AUC = 0.756) and has good predictive ability (Fig. 3).
On the basis of the three estimated logistic regression models, each group of respondents (patients, doctors and nurses) identified determinants that constitute, to varying degrees, factors influencing the quality of healthcare. The differences in perception depend on expectations arising from the treatment process and the operation of medical facilities.
Discussion
According to the study, patients overwhelmingly (76%) believe that the new competencies/authorisations can improve the quality of patient care while only 36% of doctors and 47% of nurses see such a correlation.
The advantages of nurses prescribing medications have been analysed by various authors. A study conducted by Binkowska-Bury et al. [6] analysed patients’ opinions on nurses prescribing medications. The questions also concerned possible benefits. The main advantage of using the new authorisations as perceived by respondents was a reduction in waiting times to see a doctor (55.7%). Prescribing of medications by a nurse in some cases involves a physical examination. The majority of the respondents (48.6%) believe nurses can perform examinations correctly. More than half of the respondents (47.5%) also believe that prescribing of medications by nurses does not pose a risk to their health and that nurses have adequate knowledge of their dosage (53%). Taking into account sociodemographic data such as gender, age, place of residence and education, some differences in opinions on the above topics were noted. Men, compared to women, were more positive about nurses writing prescriptions and the related tasks. However, they had higher requirements in terms of education and experience. Older patients, over 65 years of age, were more critical of nurses’ prescribing medications compared to younger patients. Other factors differentiating the respondents’ opinions on nurses prescribing medications were the place of residence and education. Rural residents and those with a higher education expressed greater approval of the new authorisations for nurses, but were not completely convinced of the ability to prescribe all medicines, but mostly supported the ability to prescribe medical devices and medicines that had previously been prescribed by a doctor [6].
The author’s study also assessed nurses’ preparedness to prescribe medicines and use new competencies/authorisations based on sociodemographic data. Positive opinions regarding nurses’ preparation for independently prescribing medicines predominated in the female group (69.21% vs. 63.24%). Women also predominate in the positive assessment of the competencies/authorisations to continue treatment (78.48% vs. 66.04%). In this survey, the largest group were respondents aged 60–69, and they most likely support the introduction of the new measures. In contrast to the Binkowska-Bury et al. study [6], in this study respondents living in both urban and rural areas and regardless of their level of education mostly believe that nurses are adequately prepared to prescribe medicines.
A study by Berry et al. [7] looked at the views of people who had never before used prescriptions written by nurses. The aim was to determine whether their confidence in nurses was similar to their confidence in doctors. The study also asked about any related concerns. The analysis of the surveys shows that the abovementioned respondents would have no problem with using this type of nursing service. They would take medicines prescribed by a nurse without any concerns. It is important for them to get accurate information about the medicine and possible side effects. It is important for patients to be provided with understandable content/clear information by healthcare professionals. This means that the respondents perceive a positive aspect of nurses prescribing medications, i.e. that they can spend more time with the nurses to provide them with information that is important to them. According to the respondents, there would be no problem with nurses taking on the new role and with relying on their experience and knowledge [7]. The analysis of own research also shows that people who have not previously had an opportunity to use nurse-prescribed medications are positive about the new measures (63%). As in the aforementioned survey, the main advantage perceived by patients is the ability to spend more time with them, e.g. to provide them with accurate information on medication dosage (69.62%).
In a study conducted by Zarzeka et al. [8] in 2019, it was noted that doctors expressed some concerns about the level of preparation of nurses to perform the newly granted professional qualifications/authorisations. Despite these doubts, doctors saw potential benefits resulting from expanding the competencies/authorisations of nurses. In particular, they emphasized that such changes can save time, both for medical staff and patients. The introduction of these qualifications/authorisations could also improve the treatment process and increase the efficiency of work in the healthcare system.
A study conducted by Brooks et al. [9] in primary care among people who had recently started to use medications prescribed by experienced nurses showed that the patients noticed the resulting benefits. This included relying on the nurse’s knowledge, observation and diagnostic skills. Other patients considered the nurses’ ability to provide information an advantage in relying on their competencies. This may be due to the fact that a doctor often cannot devote as much time to patients as a nurse due to the number of patients. Studies conducted in countries such as the United Kingdom, the United States, New Zealand, Australia, Ireland and Sweden show that nurses’ authority to write prescriptions has numerous benefits. One of the key aspects for patients is the ability to receive a detailed consultation regarding treatment [10]. The author’s study also interpreted the benefits perceived by people who use medications prescribed by a nurse. Reduced waiting time to see a doctor (82.91%), ability to access medicines quickly (71.52%), and time to discuss medication dosage were the most frequently mentioned advantages (69.62%). In a survey conducted by Bejster [11], one of the most frequently mentioned/noted benefits seen by respondents was a significant reduction in prescription waiting times. Patients often have to wait in long lines to see a doctor, which is particularly inconvenient for the elderly or those who only need to continue existing treatment. By empowering nurses to write prescriptions, the process becomes more efficient, reducing waiting times and increasing accessibility to medicines.
Limitations of work
The study also has some limitations in the generalisability of the results obtained, related to the small representation of nurses working in primary care facilities who are authorised to write prescriptions. Secondly, the study was carried out only in the Świętokrzyskie Province, which may differ in terms of employment structure, age and education of nurses and organisation of work in primary care facilities.
Conclusions
Patients rated nurses’ readiness to write prescriptions and prescribe medicines higher than nurses and doctors. They believe that nurses prescribing medications will improve the quality of healthcare services, in particular that patients will receive accurate dosage information and have quicker access to medicines. However, such an arrangement will not result in shorter waiting times for appointments with primary care physicians. The gap between patients’ expectations and medical personnel’s concerns underscores the need for training among nurses. This can allow them to acquire the necessary competencies/authorisations. It is also important to organize educational campaigns aimed at healthcare professionals, which will present the advantages of nurses writing prescriptions, and help to overcome the concerns associated with it.
Disclosures
- Institutional review board statement: Not applicable.
- Assistance with the article: None.
- Financial support and sponsorship: None.
- Conflicts of interest: None.
References
1. Ustawa z dnia 15 lipca 2011 r. o zawodach pielęgniarki i położnej [Act on the Profession of Nurse and Midwife of 15 July 2011]. Available from: https://isap.sejm.gov.pl/isap.nsf/DocDetails.xsp?id=wdu20111741039.
2.
Ministry of Health. New competences of nurses and midwives. Document developed as part of the project “Development of nursing competences” co-financed by the European Union under the European Social Fund. Warsaw; December 2020. Available from: https://akademiapp.mz.gov.pl/fileadmin/user_upload/analizy_i_raporty/12.2020_raport-_nowe_konkretcje_pielegniarek_i_poloznych.pdf - Accessed 2023.08.23.
3.
Vitale E, Cosimo DP, Attilio G, Ilaria L, Francesco G. Nursing prescription: the state of the art, results of a quantitative study. Nur Primary Care 2021; 5: 1-5.
4.
Bartosiewicz A, Binkowska-Bury M, Januszewicz P. Możliwość przepisywania recept przez pielęgniarki i położne – stan prawny w Polsce i ogólny przegląd sytuacji na świecie. Prz Med Uniw Rzesz Inst Leków 2015; 13: 290-305.
5.
Haririan H, Seresht DM, Hassankhani H, Porter JE, Wytenbroek L. Nurses, physicians and patients’ knowledge and attitudes about nurse prescribing. BMC Nurs 2022; 2: 112.
6.
Binkowska-Bury M, Bartosiewicz A, Marć M, Januszewicz P. Opinia pacjentów Podstawowej Opieki Zdrowotnej na temat ordynowania wybranych leków i wystawiania recept przez pielęgniarki. Hygeia Public Health 2016; 51: 161-170.
7.
Berry D, Courtenay M, Bersellini E. Attitudes towards, and information needs in relation to, supplementary nurse prescribing in the UK: an empirical study. J Clin Nurs 2006; 15: 22-8.
8.
Zarzeka A, Panczyk M, Belowska J, Mazur N, Lourido BP, Gotlib J. Nurse prescribing: attitudes of medical doctors towards expanding professional competencies of nurses and midwives. J Pakistan Med Assoc 2019; 69: 1199-1204.
9.
Brooks N, Otway C, Rashid C, Kilty L, Maggs C. Nurse prescribing: what do patients think? Nurs Stand 2001; 15: 33-38.
10.
Binkowska-Bury M, Więch P, Bazaliński D, Marć M, Bartosiewicz A, Januszewicz P. Nurse prescribing in Poland. Opinions expressed by primary care doctors, nurses, and patients. Medicine (Baltimore) 2016; 95: e4506.
11.
Bejster I. Opinie na temat ordynowania leków/wypisywania recept w środowisku pielęgniarek. Acta Scholae Superioris Medicinae Legnicensis 2016; 1: 26-40.
