and physicians’ perceptions of the NP role, the degree of collegiality between the NPs and physicians, and the extent to which NPs felt accepted (Fletcher et al., 2007). NPs viewed themselves as autonomous and utilized physician collaborators in a consultation role. Physicians viewed the NPs as “extenders” (who serve a purpose for the MDs) to “free‐up their time.” In both groups, the relationship between the physician and NP was seen as collegial, and physicians were satisfied with NP practice contributions. These data highlight how, despite interprofessional relationships that seem collegial and satisfying to both APRNs and MDs, physicians may maintain a traditional, hierarchical view of APRNs promoted by organized medicine. At the same time, there are many clinical settings where APRNs are viewed as colleagues. One study of primary care physicians and NPs in Missouri, a restricted practice state, revealed how physicians and NPs had similar views on many issues and their responses to each other lacked defensiveness or conflict. Moreover, NPs did not view physicians as impediments to their work with patients and physicians respected NPs and viewed their skills favorably (Kraus & DuBois, 2017).
Relationships with pharmacists are particularly important for the APRN prescriber. The pharmacist is the expert on pharmacological agents, while the APRN applies knowledge of medications contextually to the patient situation, patient preferences, and expectations of best practice. Ideally, APRNs work with pharmacists as colleagues who have the same goal of appropriate and safe medication management and a commitment to quality patient care.
A patient’s pharmacological management may involve collaboration with a specialized practitioner, for example, a physician or APRN who practices in endocrinology. Different collaborative approaches may be used.
A patient consultation is made with the specialist for evaluation and development of a medication regimen. The regimen is implemented and monitored by the APRN.
A patient is referred to a specialist who assumes care for specific health needs of the patient. The APRN typically maintains the role as the coordinator of care.
It is essential, however, that patients with a variety of complex problems who receive care from multiple specialists who prescribe medications have coordinated care and medications monitored by the primary care APRN.
Strategies for success as a prescriber
Changes in evidence‐based practice, patient‐centered outcomes research, and the introduction of new medications require regular review of patient medication regimens. A professional development plan will help the APRN utilize the most current evidence in medication management.
Participation in lifelong learning is the essence of a professional development plan. Different forms of lifelong learning may include collegial mentoring by another APRN, participation in professional organizations, informal networking with colleagues, peer review, and continuing education seminars or online training that focuses on current medication management approaches. Forty states require demonstration of continued competency to maintain licensure/recognition as an APRN; requirements vary from continuing education beyond the RN license requirement, pharmacology education, maintenance of national certification, practice, and peer review (NCSBN, 2020).
Efficient time management hinges on the APRN’s medication management expertise. One approach to enhance prescribing effectiveness is to develop a “personal formulary” of medications one typically prescribes from different drug classes or for specific health conditions. This personal formulary is developed through current evidence, experience, patient feedback and responses to medications, and financial considerations.
Besides the use of a personal formulary, the APRN may employ strategies for prescribing drugs that save time and reduce the incidence of errors in medication management. Electronic prescribing reduces errors associated with illegibly written and improper prescriptions which often require a pharmacist to seek clarification. Nonetheless, errors related to electronic prescribing occur within hospital and community settings from both the provider side and the pharmacist side (Abramson, 2015; Alex et al., 2016). The need to communicate with pharmacists continues and will facilitate medication monitoring and prescription renewal.
In the interest of safety, it is recommended that patients use one pharmacy only. In situations when the APRN is concerned a patient is misusing medications, there are programs through private and public health plans that can mandate use of one pharmacy only. Use of one pharmacy reduces medication errors, drug interactions, and multiple prescriptions from multiple providers for the same medication, particularly scheduled drugs. An example of a public program that can mandate one pharmacy only is the Washington State Medicaid program known as Patient Review and Coordination which addresses overall excess utilization of services including medication use. Clients assigned to the program have had a 33% decrease in emergency room use, 37% decrease in office visits, and 24% decrease in prescriptions (Washington State Health Care Authority, 2020).
Novice prescribers may require an extensive amount of time to consult references, electronic medication guides, and clinical guidelines to select the most appropriate medication and write prescriptions. Electronic health records (EHRs) usually provide medication choices written with the generic rather than the brand name. Sometimes the desired dose or delivery approach is not specified in the dropdown menu, so consultation with peers can be especially useful in adapting to a new EHR. Because the development of expertise will take time and occurs over months and years, APRNs are encouraged to have realistic expectations of the time required to develop competence and be patient with themselves during this process.
An analysis of how patients, prescribers, experts, and patient advocates view the prescription choice process identified five important factors: information, relationship, patient variation, practitioner variation, and role expectations. The researchers noted that “decisions regarding the selection and use of prescription medications are made by multiple individuals, at multiple times, in multiple locations, under different contexts and viewpoints. The prescription choice process may be complicated further by various abilities, beliefs, and motivations held by those involved in the decisions” (Schommer et al., 2009, p. 167). Indeed, prescribing medications may appear easy but in actuality is complex.
BARRIERS TO TRANSITIONING TO THE PRESCRIBER ROLE
Some barriers may impede rather than facilitate role transition and the APRN’s assumption of the prescriber role. Prescribing is the aspect of the APRN role most commonly constrained by legal requirements for physician collaboration or supervision. Prior to obtaining CS prescriptive authority, Washington State APRNs experienced numerous barriers to assure their patients received the CSs they needed. The three most common barriers were physician concern about possible liability as a collaborator, a physician and NP choosing different drugs, and physician reluctance to prescribe drugs selected by the NP (Kaplan & Brown, 2004). For APRNs in states with required collaborative agreements or supervision for prescribing, thoughtful conversations with a physician colleague may reduce misconceptions and discord. Even in states with full practice authority, physicians who employ APRNs may expect to have input into an APRN’s prescribing decisions.
A FRAMEWORK FOR PRESCRIBING
Rational prescribing
Rational prescribing rests on knowledge of the patient, knowledge about the nature of the health problem, and treatment using evidence‐based guidelines, standards of care, strategies for promoting medication use, health plan coverage, and socioeconomic factors. With this information, the APRN and the patient make a shared decision through consideration of the benefits and burdens in the patient’s particular situation. Both need to be mindful of the APRN’s responsibility to act in the best interest of the patient. There are four general elements to rational prescribing: knowledge of the patient, knowledge of the disease and standard management, patient education
