Nurse prescribing of medicines is a major area of interest in the scientific as well as professional literature, as shown by the high number of identified publications. This review provides insight into the diversity of external and internal forces which led to the introduction of nurse prescribing in the nine identified Western European and Anglo-Saxon countries, while shedding light on the variety of legal, educational and organizational conditions in place. Moreover, by applying Abbott's theory on the division of labor in modern societies, a variety of jurisdictional settlements between the nursing and medical professions concerning the task of prescribing were discerned.
Models of nurse prescribing and jurisdictional settlements
In the introduction to this article we briefly discussed the three general models of (nurse) prescribing usually distinguished in the literature, viz. independent prescribing, supplementary prescribing and the use of patient group directions (PGDs). However, these models appear to be largely based on the situation in the UK and may be less applicable to nurses' prescriptive authority in other Western European and Anglo-Saxon countries. For example, we found that nurses in Sweden and Ontario are only allowed to independently prescribe for a limited number of medical conditions. Hence, their prescribing practices do not fit with the common definition of 'independent prescribing' in which nurses enjoy unrestricted independent prescribing freedom with regard to medical conditions.
However, broadly speaking, all nine Western European and Anglo-Saxon countries identified in this review grant some form of independent prescribing authority to nurses, albeit with varying levels of autonomy. But where we considered 'independent prescribing' in the introduction as a situation in which both the nursing and medical professions hold equal and full jurisdiction over prescribing, according to Abbott's classification, this does not hold for all countries. Only in Ireland and the UK, where nurses' scope of prescribing practice is fairly extensive, did the level of autonomy prove sufficient to consider both the nursing and medical professions to hold equal and full jurisdiction over prescribing. All the other countries imposed such stringent restrictions on nurses' independent prescriptive authority via protocols and/or limited formularies of medicines, that the medical profession still has exclusive full jurisdiction over the prescribing task. Since nurses are often only allowed to prescribe relatively harmless medication in these countries, the medical profession has delegated to them the 'routine' part of prescribing and remains in control over the complex and professionally more important part. Hence, nurses prescribe on the basis of a subordinate jurisdiction.
Moreover, some countries such as Sweden not only place restrictions on the medicines that nurses are allowed to prescribe, but also on the type of patients for whom nurses may prescribe. Because of the inclusion of elements of client differentiation, we consider this an even more restrictive form of subordinate jurisdiction, thereby disputing Abbott's assumption that client differentiation is only a workplace settlement.
It is possible that these subordinate settlements of nurse prescribing constitute phases in a process towards shared full jurisdiction for the nursing profession. After all, the road towards extensive prescribing rights for nurses in the UK was also a gradual process, and we note that in New Zealand prescriptive authority was recently expanded to include the whole NP scope of practice [5
]. Nonetheless, movements in countries other than the UK are generally slow. In some countries, hardly any developments have been made since the initial introduction of nurse prescribing, even though nurse prescribing was sometimes introduced at a (much) earlier point in time, such as in Sweden and the USA.
Whereas all nine Western European and Anglo-Saxon countries identified in this review have granted independent prescribing authority to nurses, some of them introduced other models of nurse prescribing as well, resulting in a variety of jurisdictional settlements. The requirements of several American states regarding physician involvement in nurse prescribing creates a model of prescriptive authority comparable to supplementary prescribing in the UK. In the Netherlands specific categories of specialist nurses will in the future also prescribe through a model resembling supplementary prescribing. Because of the clear distinction between areas of responsibility, we consider both supplementary prescribing and collaborative/supervised prescribing as forms of prescribing within a 'full division of labor', in Abbott's terms. PGDs and medical directives, on the contrary, are developed by a multidisciplinary team and a physician respectively, while the nurse is the one who uses them in daily practice. Hence, the 'intellectual jurisdiction' over the prescribing task lies with the developers.
Applying Abbott's classification system of jurisdictional settlements to the prescribing scope of nurses in Western European and Anglo-Saxon countries, it is clear that the jurisdiction over the prescribing task in most countries, apart from the UK and Ireland, remains predominantly with the medical profession.
In view of the extensive prescribing privileges that nurses in Ireland and especially the UK enjoy, it is remarkable that requirements concerning number of years of clinical experience and educational level in these two countries proved less stringent than in other Western-European and Anglo-Saxon countries. Nurse prescribing training in the UK and Ireland is taught at (Honours) degree level and three years of clinical experience are required, whereas in most other countries where nurse prescribing was or is being introduced, nurses are trained at Master degree level. The number of years of clinical experience required is also higher in some countries, for example in New Zealand and Australia, where the limit is set at four and five years respectively. As Abbott states, internal and external forces shape professional competition over jurisdiction. In the UK and Ireland the emphasis was on enhancing efficiency when introducing nurse prescribing, i.e. striving for quicker and more efficient patient access to medicines and better use of health professionals' skills and knowledge. In other countries, however, more urgent internal needs such as a shortage of physicians and unmet medication needs of patients in remote areas were the most important reasons for introducing nurse prescribing. Forces focussing on efficiency seem to lead to more extensive prescribing rights, at least for nurses in Ireland and the UK. This would appear to confirm Abbott's assumption that external and internal forces shape professional competition over jurisdiction. However, because of our focus on nurse prescribing, alternatives to prescribing, such as statutory exemptions and emergency provisions, were mainly left out of this review. Nevertheless, their possible presence across countries might have influenced the conditions under which nurse prescribing was realized as well, in addition to the influence of the internal and external forces we examined.
Perhaps the question as to whether or not national medical associations support the nurse prescribing initiative is also important when it comes to nurses' prescriptive authority. It is established that the British Medical Association in the UK has supported the nurse prescribing initiative from the outset [85
] and this may have been beneficial to its extensive roll out. By contrast, in Australia, Spain and the USA, professional medical organizations have mainly opposed nurse prescribing [5
], which may equally explain the relatively limited prescribing rights of US nurses, especially in view of the much longer period of familiarity with nurse prescribing in the USA compared to the UK.
However, on the basis of current data no definitive conclusions can be drawn about underlying mechanisms that operate between the forces that led to the introduction of nurse prescribing internationally and the scope of prescribing rights nurses enjoy. It would be interesting to further examine these mechanisms, preferably in a quantitative manner. Data on the percentage of total healthcare expenditure on medicines, number of physicians per capita and time of introduction of nurse prescribing could for example be used in an ecological analysis.
Gaps in the literature
An interesting finding in this review is the near absence in the literature of reference to practice-related and organizational conditions under which nurses are allowed to prescribe medicines. This hinders a comparison and further theoretical interpretation of the organization of nurse prescribing internationally. For example, even though we found that most countries have mandatory registration systems in place for nurse prescribers, it remains unclear whether all nurses have individually registered provider numbers. However, where prescribing has been introduced to improve cost-effectiveness, individual provider numbers are needed to thoroughly monitor who prescribes which medicines how often and ascertain whether the implementation of nurse prescribing has had its intended effect.
When it comes to financial issues, likewise, many questions remain unanswered in the literature. What became clear however, is that reimbursement issues are not always properly catered for and this can, even with an otherwise good organisation, have far-reaching consequences for the success of nurse prescribing. For example, where medicines prescribed by nurses are not (fully) covered by insurance providers and/or national health programs, such as in some American states, this can generate an unfavourable reaction from the public towards nurse prescribing. Patients will prefer their physician to write their prescriptions, as reimbursement issues for this profession are well arranged. Consequently nurses might lose part of their workplace jurisdiction to the medical profession, who in their turn will claim more legal jurisdiction. Moreover, the fact that nurses' prescriptions are not always eligible for reimbursement underlines once more the full jurisdiction that medicine still has over prescribing, despite nurses' (limited) independent prescribing rights.
While we do not say that the organizational conditions have not been properly addressed across countries, they are largely missing from the literature. Both for interpreting the organization of nurse prescribing on a theoretical basis and for critically monitoring whether expected goals are being met, it is important that organizational conditions - as much as educational and legal conditions - are extensively discussed in the nurse prescribing literature.
It could be argued that this systematic review does not give a complete picture of the state of the art, as a number of policy documents and other relevant grey literature might potentially have been excluded from the review by our choice of search strategy. We choose this strategy, however, to safeguard the quality of sources. Even though the number of references to the organizational conditions under which nurses prescribe medicines as identified in this review proved somewhat disappointing, it is unlikely that this is due to our search strategy, as the educational and legal conditions under which nurses are allowed to prescribe medicines were sufficiently addressed in the identified literature.
Furthermore, as nurse prescribing is still in the process of development, there is a possibility that some of the included literature may be out of date in certain respects or doesn't contain the most recent developments in nurse prescribing. We tried to prevent this by including only publications from 2005 onwards that discussed the legal, educational and organizational conditions under which nurses are allowed to prescribe medicines. Nevertheless, it might prove beneficial to conduct a further survey among relevant stakeholders across all Western European and Anglo-Saxon countries that have realised or initiated nurse prescribing. This might also shed light on information that was largely missing from the scientific and professional literature, such as the organizational conditions under which nurse prescribing has been or will be realised internationally.
Challenges for future research
Future research should provide more insight into the organizational and more especially the financial conditions under which nurses prescribe. These are not only important in everyday practice but are also indicators for the potential efficiency of nurse prescribing. There is also a need for more theory-based research on nurse prescribing. For example, we do not know how nurses' legal and workplace jurisdictions over prescribing relate to each other once legal prescriptive authority is obtained. There are indications that qualified nurse prescribers in the UK are not (fully) using their legal prescribing rights on the work floor, partly because of their own uncertainty about their educational preparation and partly resulting from organizational conditions such as a lack of system change within their work environment [36
]. Future research should address this discrepancy between obtained legal authority and workplace jurisdiction. It is important to examine which mechanisms and forces influence this relationship.