Prescribing Competencies for Advanced Practice Registered Nurses
Article Outline
- Abstract
- Background
- Definitions
- APRN Prescribing
- Prescribing Competencies
- Purpose
- Methods
- Results
- Discussion
- Limitations of the Study
- Recommendations
- References
- Copyright
Abstract
Both educators and regulators have an interest in determining if advanced practice registered nurses (APRNs) are prepared to obtain prescriptive authority. A study was conducted to confirm competencies that could be adopted to prepare APRNs for prescribing. Prescribing competencies can serve as the foundation for evidence-based legislation, and regulation by state boards, which could allow APRNs to reach their full potential.
Keywords: advanced practice registered nurses , advanced practice registered nurses education , competencies , prescribing , prescriptive authority
Advanced practice registered nurses (APRNs) have autonomous prescriptive authority in only 13 states and the District of Columbia.1 Nonetheless, the role of the APRN as a prescriber is expanding as a result of legislative successes over the last few years. For example, Washington prescribing for controlled substances became fully autonomous in 2005, nurse practitioners (NPs) in Georgia obtained prescriptive authority in 2006, and Oregon eliminated the requirement for a formulary in 2008. Although APRN prescribing has been authorized in the United States for over 30 years, there are limited data regarding the transition to the APRN prescriber role.
Oregon serves as an example of regulatory evolution, having enacted a series of legislative changes recognizing and expanding the APRN role. NPs in Oregon obtained independent practice in 1977 and autonomous prescriptive authority in 1979. Clinical nurse specialists (CNSs) obtained the legal option to become licensed as APRNs in 2002 and earned autonomous prescriptive authority in 2005. Oregon law provides for autonomous prescribing and dispensing of medications, including schedule II-V narcotics.2
CNS educational programs typically do not prepare students to prescribe, while NP programs require pharmacology coursework and integration of prescribing for individuals in clinical practica. This educational disparity created a regulatory challenge to implement the 2005 law. The Oregon State Board of Nursing (OSBN) developed eligibility criteria for CNS prescriptive authority, which includes a supervised prescribing practicum offered for academic or continuing education credit. NPs who do not meet eligibility criteria for prescriptive authority must also complete the practicum. The purpose of this article is to present results of a study confirming prescribing competencies included in a tool used to evaluate the prescribing practicum.
Background
In 1999, the Institute of Medicine (IOM) issued the report “To Err is Human: Building a Safer Health System”,3 which brought attention to the fact that medication errors are a significant source of poor patient outcomes. Communication and system breakdowns were identified as the source of many errors in health care delivery. The report estimated that costs for drug-related morbidity exceeded $177 billion. The Institute for Safe Medication Practices4 reported that, for the first quarter of 2008, a record number of 4824 deaths and 20,745 serious injuries associated with drug therapy were reported to the U.S. Food and Drug Administration. As a voluntary reporting system, this likely does not accurately represent the extent of the problem.
Definitions
Prescribing
There is wide variability in the definition and use of the term prescribing. The Oregon Nurse Practice Act defines prescribing as instruction related to a medication or preparation for use by human beings “to direct, order, or designate the preparation, use of or manner of using by spoken or written words or other means.”5 Initially written for NPs, the definition was amended in 2005 to add CNSs.6
Competence and Competency
Competence refers to an individual's overall ability, while competency is an outcome that measures a specific skill or ability the individual must obtain or master. A common understanding of competency does not exist, and the terms “competence” and “competency” are used interchangeably in the literature.7 Initial and continued competence is another level of distinction, with continued competence focusing on processes used to assess the basis for maintenance of health professional licensure.8
APRN Prescribing
NPs have prescriptive authority in all 50 states and the District of Columbia, although this ranges from a delegated authority requiring physician-supervised protocols to full autonomy. Not all states grant NPs prescribing authority for controlled substances. Some states also do not grant prescriptive authority to nurse midwives, nurse anesthetists, or CNSs. An improved regulatory environment over the last decade has increased the number of APRN prescribers and their scope.1
APRNs obtain prescriptive authority concurrent with or subsequent to initial APRN licensure. Some states grant prescriptive authority if educational requirements are met. Other states have educational and supervised prescribing practicum requirements. There are no standardized metrics used to confirm an individual's competency before granting prescriptive authority. Most studies of APRN prescribing in the United States focus on prescribing patterns,9, 10, 11, 12, 13 comparing APRN prescribing to that of physicians or other providers,14, 15, 16 and comparing NP and CNS prescribing.17 Studies evaluating prescribing education and prescribing competencies for nurse prescribers have been conducted in England.18, 19 The lack of U.S.-based studies that evaluate prescriber competencies leads to a lack of evidence-based guidelines that can be used by educators and regulators.
Prescribing Competencies
Educational and practice competencies for health professionals generally do not include any specific to prescribing. This is true of the core competencies of the American College of Nurse Midwives20 and the general competencies of the Accreditation Council for Graduate Medical Education.21 The American Association of Colleges of Nursing has 2 documents regarding the “essentials” of advanced practice nursing education.22, 23 They describe the purpose of APN pharmacology content to prepare the graduate to “…assess, diagnose, and manage (including the prescription of pharmacologic agents) a client's common health problems in a safe, high quality, cost effective manner.”(p.14,24)
The National Organization of Nurse Practitioner Faculties (NONPF) 2006 core competencies24 include only one related to prescribing: “prescribes medications within legal authorization.”(p. 2) NONPF collaborated on the creation of The 1998 Curriculum Guidelines & Regulatory Criteria for Family Nurse Practitioners Seeking Prescriptive Authority to Manage Pharmacotherapeutics in Primary Care.25 This includes 16 end-of-program prescribing competencies. These competencies are now more than a decade old and have not been further validated, but serve as an important resource when considering what prescribing competencies APRNs require. The National Association of Clinical Nurse Specialists identified 75 core competencies for clinical practice; however, none address prescribing, dispensing, administering, or evaluating medications used by individual patients.26
Purpose
This study was conducted to confirm the prescribing competencies developed by the OSBN for the evaluation of APRNs at completion of a prescribing practicum. The study also compared the perspectives of various APRN groups and students, with and without prescriptive authority, regarding what prescribing competencies are necessary.
Methods
This quantitative descriptive exploratory study utilized survey methodology. The study's principal investigator (PI) developed a 42-item questionnaire that contained 11 demographic questions and the 31 competencies included on the OSBN practicum evaluation tool. These competencies encompassed 7 domains adapted from the American Nurses Association's “Nursing: Scope and Standards of Practice.”27 The domains are assessment/data collection, analysis, planning, implementation, evaluation, professional behaviors, and communication. Study participants were asked to evaluate each competency using a 5-point Likert scale: not at all essential, neutral, somewhat essential, very important, and mandatory, defined as “a nurse should not be granted prescriptive authority without it.” The competencies included in the tool were selected following a review of the literature; however, there was a paucity of prescribing competencies research for NPs in the United States. Studies from pharmacy and psychology, and from Canada and the United Kingdom, were included in the review.28, 29, 30, 31, 32
Collection of Data
After receiving Institutional Review Board approval from the university, a pilot study was conducted with the Washington State University NP faculty (n = 9) to determine the questionnaire's utility, efficacy, and ease of administration. The questionnaire was mailed to all licensed Oregon CNSs to whom the new law directly related. A second mailing occurred 1 month later to encourage participation. The questionnaire was mailed once to the FNP students in a clinical practicum that included learning to apply prescribing skills, and to preceptors experienced in evaluating students on prescribing skills. The questionnaire was distributed at a conference to NPs expected to have prescribing experience.
All responses were anonymous, with results reported in aggregate. A total of 167 valid questionnaires were returned. The CNS response rate was 60%; the preceptor response rate was 39%; the student response rate was 27%. It was not possible to calculate a response rate for the NPs who received the questionnaire at a regional conference.
Analysis
Descriptive statistics were combined to create a frequency variable used to rank the competencies in order of identified importance. Once the competencies were ranked, the domains in which the most and least important competencies occurred were analyzed. Comparison between groups was also conducted using the ratings and rankings.
Results
Table 1 summarizes the characteristics of the respondents. There were 72 CNSs, 73 NPs, 14 dually certified CNSs/NPs, 1 physician, and 7 FNP students. The majority (69%) had a master's degree as the highest level of education. The average age was 50.4 years, with half 53 years or older, and one quarter 57 years or older.
Table 1. Characteristics of Respondents
| Number | Percentage | |
|---|---|---|
| Role | ||
| CNS | 72 | 43 |
| CNS/NP | 14 | 8 |
| NP | 73 | 44 |
| MD | 1 | < 1 |
| Student NPs | 7 | 4 |
| Highest Degree | ||
| Baccalaureate | 8 | 5 |
| Master's | 115 | 69 |
| Post-master's | 20 | 12 |
| PhD | 15 | 9 |
| Clinical doctorate | 5 | 3 |
| Other | 4 | 2 |
| Gender | ||
| Female | 154 | 92 |
| Male | 13 | 8 |
| Age | ||
| Average (years) | 50.4 | |
| Range (years) | 28–65 | |
| Quartiles (years) | ||
| 28–45 | n = 38 | |
| 46–52 | n = 44 | |
| 53–56 | n = 40 | |
| 57–65 | n = 43 | |
| Years of APN Practice | ||
| Years as a CNS | ||
| Range | 0–37 | |
| Average | 12.6 | |
| Years as an NP | ||
| Range | 0–34 | |
| Average | 13.2 |
A prescribing profile of the respondents is presented in Table 2. Half of the sample (51%), reported having prescriptive authority. Only 3 CNSs had prescriptive authority; 10 CNSs also certified as NPs had prescriptive authority, and 70 NPs had prescriptive authority. There was also 1 physician prescriber. Almost all prescribers (94%) were registered with the Drug Enforcement Administration (DEA), a requirement for prescribing controlled substances. One third (32%) of respondents with prescriptive authority and DEA registration who provided direct patient care prescribed 16 or more controlled substances a week, with one quarter (24%) prescribing none or 1 controlled substance a week.
Table 2. Prescribing Profile
| Number | Percentage | |
|---|---|---|
| Prescriptive authority | 84 | 51% of total sample |
| CNS | 3 | |
| NP/CNS | 10 | |
| NPs | 70 | |
| Physicians | 1 | |
| DEA registration | 79 | 94% of NPs/CNSs with prescriptive authority |
| Hours practiced/week if has a DEA number | Avg 32.1 | |
| Range 0-55 | ||
| No. of controlled substances prescriptions/week | ||
| 0 | 6 | 7 |
| 1 | 14 | 17 |
| 2-5 | 15 | 18 |
| 6-10 | 13 | 16 |
| 11-15 | 8 | 10 |
| 16 or more | 26 | 32 |
Almost all prescribing competencies listed were rated as either “very important” or “mandatory.” No competency was rated “not essential.” Table 3 contains the top 10 prescribing competencies and their domains as reported by the entire sample. Table 4 lists the 5 least important competencies. Table 5 compares the top 10 competencies as reported by respondents with and without prescriptive authority.
Table 3. Top 10 Prescribing Competencies - All Respondents
| Competency | Domain |
|---|---|
| Determines appropriate drug therapy | Planning |
| Writes clear, legible and complete prescriptions | Implementation |
| Prescribes in accordance with current professional codes | Professional behaviors |
| Demonstrates competency in drug dosage calculation | Implementation |
| Interprets tests and identifies client-specific factors | Analysis |
| Plans drug regimens | Planning |
| Accurately performs medical history | Assessment/data collection |
| Prescribes based on pharmacological and physiological principles | Implementation |
| Monitors safety and efficacy of drug treatment plan | Evaluation |
| Establishes and documents medical diagnosis | Analysis |
| Demonstrates ownership of and responsibility for the welfare of the client | Professional behaviors |
Table 4. Five Least Important Prescribing Competencies - All Respondents
| Domain | |
|---|---|
| Assesses client health care risks | Assessment/data collection |
| Evaluates own practice for continuous improvement | Professional behaviors |
| Assesses the client's therapeutic self-management | Assessment/data collection |
| Adapts communication style to meet needs of client | Communication |
| Demonstrates effective working relationship with health care team | Professional behaviors |
Table 5. Top 10 Prescribing Competencies Comparing Respondents With and Without Prescriptive Authority
| WITH Prescriptive Authority (n = 84) | WITHOUT Prescriptive Authority (n = 82) |
|---|---|
| Writes clear, legible, and complete prescriptions | Determines appropriate drug therapy |
| Determines appropriate drug therapy | Writes clear, legible, and complete prescriptions |
| Prescribes in accordance with current professional codes | Demonstrates competency in drug dosage calculation |
| Demonstrates competency in drug dosage calculation | Prescribes based on pharmacological and physiological principles |
| Interprets tests and identifies client-specific factors | |
| Provides client-specific education about medications | Prescribes in accordance with current professional codes |
| Monitors safety and efficacy of drug treatment plan | Plans drug regimens |
| Establishes and documents medical diagnosis | Interprets tests and identifies client-specific factors |
| Demonstrates ownership of and responsibility for the welfare of the client | Interprets and applies pharmacological principles in evaluation and selection of drug therapy |
| Plans drug regimens | Accurately performs medical history |
| Accurately and promptly records clinical notes of assessment and pharmacological plan |
The top 10 competencies represented 6 of the 7 domains; no competency was from the domain of communication. None of the 4 communication competencies was in the top half of the rankings and “adapting communication style to meet the needs of the client” was next to the last in importance for all respondents. Determining drug therapy ranked as the most important competency and writing a clear, legible prescription was number two.
Comparison between groups
Several comparisons between the rankings of competencies by CNSs and NPs were of interest. CNSs ranked prescribing based on pharmacological and physiological principles third, while NPs ranked this 13th. CNSs placed more importance on planning drug regimens (ranked fifth), than did NPs (ranked 10th). NPs, however, ranked ownership for the welfare of the client higher (ranked fifth) than did CNSs (ranked 13th).
One notable comparison between faculty and student responders related to documentation. Faculty ranked the accurate and prompt recording of clinical notes, which reflect client assessment and the pharmacological management plan, third. Students ranked this competency last.
Discussion
The respondents were a highly experienced group of APRNs with a comparable number of CNSs and NPs with similar years of experience. Almost every competency was rated mandatory or very important and confirmed that all 31 competencies were perceived as essential to the prescribing role. Determining appropriate drug therapy, including: dose, dosage form, route, and frequency of administration ranked as the most important competency. This competency is part of the planning domain, documented by writing a prescription, making it “visible,” and should be evidence based. It can be evaluated by the patient, pharmacist, and colleagues.
The communication domain ranked lowest overall and by prescribers and non-prescribers, even though the majority of medication errors can be traced primarily to lack of communication.3, 33, 34 The importance of communication in prescribing cannot be overemphasized. Studies suggest that more than 60% of medication errors are caused by mistakes in interpersonal communication.35 According to the Joint Commission, communication is a top contributor to sentinel events.36
Communication is also central to the concept of concordance, which is the process by which the patient and health professional come to agreement on if and how a drug will be used. Concordance requires a health professional to acknowledge that providing a prescription results from mutual decision-making with the patient. Key elements of communication necessary to achieve concordance include identifying and exploring the patient's perspective on the possibility of taking medication, providing information regarding the pros and cons of taking or not taking medication, and assuring that the patient is engaged in treatment decisions initially and over time.37
A comparison between respondents with and without prescriptive authority was, for the most part, a comparison between NPs and CNSs. Providing client education, a related competency from the domain of implementation, was ranked 6th by people with prescriptive authority but 14th by those without. This suggests that prescribers have a heightened awareness of the need to provide patients with information necessary for the safe and effective use of medications rather than relying on a pharmacist or other health professionals to provide the education. Respondents with prescriptive authority ranked prescribing based on knowledge principles 12th compared to those without prescriptive authority, who ranked it 4th. Prescribers may rely more on their practical experience, including observations of how people respond to medications, recommendations from colleagues, influence by pharmaceutical industry representatives, and pressure from patients. Respondents without prescriptive authority may see this competency as more important because they would need to acquire or apply this knowledge to become prescribers.
Limitations of the Study
It is possible that competencies essential to the prescribing role were not included in the study. Nearly all the responses were either very important or mandatory, and it is difficult to discern why there was less distribution of the responses. It is not known how non-responders compare to responders, and how representative the sample is of all CNSs and NPs. It is unknown how many CNSs without prescriptive authority have completed a graduate-level pharmacology course intended for prescribers.
Recommendations
The study findings suggest that educators should introduce prescribing competencies to students as part of their pharmacology course. The competencies should also be integrated throughout the rest of the APRN program, with confirmation of specific prescribing competencies into ongoing clinical assessment. This could demonstrate that the prescribing experience gained during clinical practica prepared the student for initial prescriptive authority. Educators should also consider providing a prescribing competency tool to preceptors to ensure they offer students clinical opportunities to develop them. Moreover, preceptors should receive guidance in using the tool for evaluation of the student.
Given the extensive changes in pharmacology and prescriptive authority regulation over the last decade, review and re-evaluation of the limited existing competencies is advised. National APRN organizations could adopt these or similar updated competencies, which should be developed to prepare APRNs for autonomous prescribing. APRNs who practice in states without autonomous prescribing will have a foundation to transition to a new scope of practice when legislative changes occur.36
APRNs have a professional responsibility to advocate and prepare for scope of practice changes. In some situations, APRNs accept legislative constraints that restrict their ability to practice to the full extent of their skills, knowledge, and abilities. These restrictions become normalized as “good enough.”38 APRNs need to both change laws and prepare for change in scope of practice. According to Kaplan and Brown,38 APRNs, professional organizations, and APRN faculty should consider the strategies in Figure 1 for facilitating readiness for change.
Figure 1.
Strategies for Facilitating Readiness for Change.38
From a regulatory standpoint, demonstration of these outcome-based competencies in educational programs could be used to eliminate or prevent the requirement for supervised prescribing. Oregon's experience in developing a regulatory model for adding autonomous prescriptive authority can serve as a model for other states. Moreover, prescribing competencies could serve as a basis for national guidelines that could be used to support autonomous prescribing in all states. Historically, passage and implementation of prescriptive authority laws were often based upon political and social cooperation or political pressures and interests. Prescribing competencies can serve as the foundation for evidence-based legislation and regulation by state boards, which could allow APRNs to reach their full potential.
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In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
PII: S1555-4155(09)00580-7
doi:10.1016/j.nurpra.2009.09.016
© 2010 American College of Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
Refers to erratum:
- Erratum