An investigation into the decision-making processes of nurse prescribers in the management of acute illness in complex patients presenting to General Practice using think aloud and staged vignettes.

Abstract

Nurses in general practice are increasingly taking on traditional medical roles such as diagnosis and prescribing of medicines to meet the growing demands of general practice. Additionally, they face increasingly complex decision-making in a society where it is common for older adults to have two or more chronic conditions (multi-morbidity) and to be taking multiple medications (polypharmacy). It is known that prescribing for such patients is complex and a cause of frequent error in general practice. Nurse independent prescribers (NIPs) are required to be competent in assessment and diagnosis prior to undertaking prescribing training but there is no standard pathway or training to prepare nurses for this role. NIPs in general practice frequently undertake the assessment of patients presenting acutely with undifferentiated and undiagnosed conditions in an increasingly complex population. Complex decision-making is a key requisite for nurses undertaking these roles in general practice, yet little is known about the decision-making processes of this group of prescribers.
This study used think aloud method in response to complex vignettes to explore NIPs’ decision-making processes. A novel use of staged vignettes was piloted and used to maximise insights into the complexity of decision-making associated with the assessment and treatment of this patient group. In addition, semi-structured interviews were used to explore how NIPs justified and explained their decision-making. Fourteen general practice NIPs whose role included the assessment and treatment of patients presenting with undifferentiated and undiagnosed conditions participated in the study and data collection continued until data saturation was achieved. Thematic analysis was used to analyse think aloud data and data from semi-structured interviews.
The study findings showed NIPs’ decision-making in response to complex vignettes to be underpinned by both analytical and intuitive processes, the quality of which were dependent on the knowledge, experience and clinical exposure of individual NIPs. There was a wide range of
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clinical experience and academic qualifications amongst the NIPs which revealed pockets of expertise in dealing with some vignettes and a high level of referral to the GP for others. This varied between and amongst the participating NIPs. The use of intuitive processes by some participants was facilitating in the management of uncertainty and complexity in some vignettes but represented an area of risk where it was relied on to determine the content of the consultation and meant that some complex aspects of the vignettes such as non-adherence to medication were overlooked.
Several organisational factors were shown to influence the decision-making of NIPs. The majority of NIPs undertook independent, time-limited clinics which were found to shape the content of their consultations and encourage a satisficing approach to complex presentations informed by intuitive processes and risked incomplete assessments. Furthermore, the pressure of time reduced the opportunity for mentorship and development. A minority of NIPs worked alongside GPs and a team approach was taken which enabled flexibility in consultation times, appropriate allocation of skills and encouraged mentorship and support from GPs.
This study has shown NIPs bring valuable expertise to the management of complex patients presenting acutely to general practice. Sound underpinning knowledge alongside clinical experience and exposure is critical to ensure optimal decision-making by NIPs managing this group of patients. Furthermore, NIPs require both adequate time in which to undertake consultations to ensure aspects of complexity are not overlooked, and accessible support from GPs in order to develop their practice.
Consideration needs to be given to the working practices of NIPs in general practice to ensure that their expertise is appropriately used and that mentorship and opportunities for development are available in order to maximise their contribution to the general practice workforce and improve patient experience. Adopting a team approach to managing this patient group has the potential to reduce the pressure of time limited appointments and allow individual expertise to be targeted to enhance patient care and provide opportunities for learning and development. Furthermore, dedicated teaching addressing complex patient presentations should be considered by Higher Education Institutions as a priority for the non-medical prescribing curriculum.

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ORCID for Sue Latter: orcid.org/0000-0003-0973-0512

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