The Barriers to Nurses with Prescriptive Authority in Exercising Their Prescriptive Role: A Systematic Review and Thematic Synthesis of Qualitative Studies

Abstract

This systematic review investigates the barriers experienced by nurses with prescriptive authority and their required supports to strengthen and sustain nurse prescribing. Empirical qualitative studies indexed in Embase, MEDLINE, CINAHL, and ProQuest from inception through 31 December 2023 were screened, yielding 27 eligible articles. Data were synthesized with Thomas and Harden’s three-stage inductive approach which included: line-by-line coding, construction of descriptive themes, and generation of analytical themes. Two overarching analytical themes were constructed — “The Undervaluing of Nurse Prescribers” and “The Need for a Supportive System”. Each encompassed several subthemes that expose pervasive misconceptions about, and systemic undervaluation of, nurse prescribers’ expertise. The review underscores the imperative for comprehensive organizational and policy support to strengthen nurse prescribers’ autonomy, confidence, and effectiveness. Because most of the included studies originated from high-income Western countries, future research is needed to examine nurse prescribing in low- and middle-income settings.

Keywords

nurse prescribing prescriptive authority barriers to practice qualitative synthesis systematic review thematic analysis

Introduction

Nurse prescribing refers to the formal right granted to certain categories of nurses to prescribe medications within a regulated framework (Maier, 2019; Maier et al., 2017). Despite variations in nurse prescribing models across countries (International Council of Nurses [ICN], 2021), two main models are commonly recognized: independent and supplementary prescribing. Independent nurse prescribers are authorized to assess, diagnose, and prescribe autonomously, while supplementary prescribers issue medications from a predefined formulary in consultation with an independent prescriber (ICN, 2021). High-income countries such as Australia, Canada, New Zealand, and the United States have granted advanced practice nurses (APNs) with master’s degrees the authority to prescribe a broad range of medicines (Maier, 2019). The categories of nurses permitted to prescribe vary; in some countries, only APNs have independent prescribing rights within their specialty (Maier, 2019).

Nurse prescribing represents a form of task shifting from physicians to nurses, emerging as a strategy to address physician shortages while improving healthcare quality and efficiency (Ecker et al., 2020; Lovink et al., 2022). It enhances various aspects of nursing practice and integrates previously distinct elements of patient care. Numerous benefits of nurse prescribing have been documented, including reduced physician workload, improved patient access to care, and enhanced quality of care and patient satisfaction (Casey et al., 2020; Nuttall, 2018; Zimmermann et al., 2020). However, nurse prescribing has also faced resistance from some physicians, patients, and even fellow nurses since its inception (Graham-Clarke et al., 2018; Jodaki et al., 2024; Noblet et al., 2017).

Over the past five decades, nurse prescribing has gradually expanded worldwide. The United States first introduced prescribing for nurse practitioners in the 1960s (Brown & Draye, 2003). By 2021, 44 countries and regions had granted some form of prescribing authority to nurses, reflecting a global trend to optimize healthcare delivery and alleviate workforce shortages (ICN, 2021). The pace of implementation varies widely. Some high-income countries have well-established systems enabling task shifting to nurse prescribers, whereas others are still in exploratory phases or lack legal recognition for nurse prescribing (Maier, 2019). The ICN has advocated for national or local evaluations of nurse prescribing as a means to enhance patient safety, ensure continuity of care, achieve universal health coverage, and address primary care gaps exacerbated by the COVID-19 pandemic (ICN, 2021). In recent years, nurse prescribing has become a focal point of global research, with some studies exploring how supervised prescribing models might be implemented (Fox et al., 2022) while other countries are only beginning to recognize the potential of introducing nurse prescribing (Almotairy et al., 2023; Babaei et al., 2022; Ling et al., 2021).

Given the uneven global development of prescriptive authority for nurses, it is crucial to examine nurse prescribers’ experiences across different regions to identify common challenges and potential solutions. Moreover, a recent protocol highlighted the lack of evidence from nurses’ perspectives on this issue in a global context (Sunzi et al., 2024). Understanding nurses’ first-hand experiences with prescribing is essential, as they directly encounter the challenges associated with prescriptive authority in practice (Walker et al., 2019).

A growing number of qualitative studies on nurse prescribing provide an opportunity to gain these insights on a global scale. Therefore, this review synthesizes empirical qualitative research on nurse prescribers’ experiences to answer the questions: What barriers do nurses with prescriptive authority face in exercising their prescribing role, and what support do they need to achieve full competency? By drawing on international experiences, the findings aim to illuminate the nature of nurse prescribing in practice and guide countries in the early stages of developing nurse prescribing systems. Anticipating these challenges can help nurses and stakeholders implement effective solutions, ultimately building a strong foundation for nurse prescribing and improving its integration into healthcare systems.

Methodology

This systematic review and thematic synthesis of qualitative studies was registered in PROSPERO (CRD42023463438). The reporting followed the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework to ensure a transparent review process (Tong et al., 2012).

Eligibility Criteria

Publications were eligible for inclusion if they: (1) were empirical qualitative studies, (2) included nurses with prescriptive authority or prescribing experience (regardless of the prescriptive authority model), (3) were published in English, and (4) were available in full text. Mixed-methods studies were excluded to avoid compromising contextual coherence and methodological rigor, as their qualitative findings are often intertwined with quantitative data. Additionally, mixed-methods studies typically provide limited qualitative detail due to publication constraints, potentially undermining the depth and interpretive quality required for a robust thematic synthesis.

Search Methods

Relevant studies published from inception up to December 31, 2023, were identified through comprehensive searches of Embase, MEDLINE, CINAHL, and ProQuest. Search strategies were tailored to each database with no date restrictions, using truncation symbols to broaden the search and Boolean operators (AND/OR) to combine terms. The reference lists of all identified studies were also screened for additional eligible publications. Two reviewers (J.X. and L.Q.) independently screened titles and abstracts for eligibility, resolving any disagreements through discussion. Full-text articles of all studies that passed the initial screening were retrieved and assessed independently by the same two reviewers using EndNote 21 for reference management. Twenty-seven studies met the inclusion criteria and were included in the review. A PRISMA flowchart diagram (Figure 1) illustrates the search and screening process. The PRISMA flowchart was created using the Shiny App (Haddaway et al., 2022).

Figure 1.

PRISMA Flowchart Diagram (Page et al., 2021).

Quality Appraisal

Two reviewers (J.X. and L.Q.) independently appraised the quality of each included study using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Research Evidence Appraisal Tool (Dang et al., 2022). This tool evaluates qualitative studies based on six criteria: transparency, diligence, verification, self-reflection (or self-scrutiny), participant-driven inquiry, and insightful interpretation. Studies meeting all six criteria were rated as high quality (Grade A), while those meeting three to five criteria were considered good quality (Grade B). Only Grade A or B studies were included in the synthesis. Among the 27 articles, 5 were Grade A and 22 were Grade B; no studies were excluded for low quality.

Synthesis

We applied an inductive thematic synthesis following Thomas and Harden’s (2008) three-stage approach: coding the text line-by-line, developing descriptive themes, and generating analytical themes. Using NVivo 14 (Lumivero, 2023), we coded concepts related to nurses’ perspectives on barriers to prescribing practice, as well as the need for support to achieve full competency. Codes were iteratively organized into descriptive themes, and relationships among these themes were examined across all studies to formulate higher-order analytical themes. The analysis was iterative: each article was revisited to ensure all relevant data were captured and appropriately categorized into a hierarchical framework of themes and subthemes. To enhance the trustworthiness of the synthesis, an inter-rater reliability check was performed. Two researchers (J.X. and L.Q.) independently coded three randomly selected articles and compared the results. Discrepancies were resolved through team discussion with input from an experienced qualitative researcher (A.M.). Inter-rater agreement was 99% to 100%, with Cohen’s kappa ranging from 0.86 to 1.0, indicating strong reliability (Landis & Koch, 1977). After establishing a stable coding framework, the primary reviewer (J.X.) coded the remaining articles, with regular team meetings to discuss progress, address issues, and refine the synthesis of the initially constructed themes.

Ethical Considerations

Ethics approval was not required for this systematic review and thematic synthesis.

Results

Characteristics of Included Studies

All 27 included studies were conducted in Western developed countries, predominantly in the United Kingdom (18 studies), followed by Ireland (4), New Zealand (2), Spain (1), the United States (1), and Canada (1). Together, these studies examined the experiences of 391 nurse prescribers. Regarding study design, nine studies were phenomenological, seven were case studies, one used grounded theory, and one used ethnomethodology; the remaining nine did not specify a qualitative philosophical methodology used. All studies collected data through individual interviews or focus groups. Most studies employed purposive sampling (26 studies), with one using convenience sampling. The most common analytic approach was thematic analysis (22 studies), with others using the constant comparative method (2), grounded theory analysis (1), descriptive coding with reflexive reading (1), and framework matrix analysis (1).

Table 1 shows the Characteristics of Included Studies.

Table 1.

Characteristics of Included Studies.

Authors, Year	Aims	Methodology; Sampling & Data Collection Method	Participants	Location	Data Analysis	Main Findings	Quality Rating
Abuzour et al. (2018a)	To explore what influences secondary care pharmacist and nurse independent prescribers during the process of clinical reasoning when addressing prescribing scenarios.	An exploratory case study; purposive sampling; the think-aloud methodology and semi-structured interviews.	10 pharmacists and 11 nurse independent prescribers working in secondary care.	United Kingdom	Constant comparative method	1. Intrinsic factors: 1) education 2) experience 3) metacognition 4) identity 5) attitudes. 2. Contextual factors 1) resources 2) prescribing settings 3) trust requirements 4) cost 5) meetings. 3. Social interactions 1) interprofessional team 2) patient/carers/family and friends.	III A
Abuzour et al. (2018b)	To explore how pharmacist and nurse independent prescribers in secondary care clinically reason when addressing prescribing scenarios.	An exploratory case study; purposive sampling; think-aloud methodology and semi-structured interviews.	11 nurse and 10 pharmacist independent prescribers.	United Kingdom	Constant comparative method	A decision-making model was presented: 1) encompassing case familiarization, 2) generating hypotheses, 3) case assessment, 4) final hypotheses and 5) decision-making stages.	III A
Bowskill et al. (2013)	To investigate how nurse prescribers agree their prescribing role and start prescribing for patients in practice.	A case study; purposive sampling; semi-structured interviews.	26 nurse prescribers were interviewed in case studies of primary and secondary care prescribing.	United Kingdom	Simple descriptive codes and reﬂexive reading techniques	1) Prescribing in practice, 2) prescribing relationships; 3) prescribing agreements.	III B
Bradley et al. (2007)	To explore how nurse prescribers could be supported in their prescribing practice, and how prescribing competencies could be assessed and reviewed.	Grounded theory; purposive sampling; semi-structured interview.	31 qualiﬁed nurse prescribers from acute care and community settings, 74% had prescribed medication.	United Kingdom	Grounded theory	1) Safety, 2) becoming conﬁdent and competent, 3) support.	III B
Canet-Vélez et al. (2023)	To describe the experience of nurses regarding the rollout and implementation of nursing prescriptions within Catalonia’s electronic prescription system.	The specific methodology was not indicated; purposive sampling; semi-structured individual interviews and discussion groups.	24 nurses who were accredited in nurse prescribing or involved in the rollout of nurse prescribing.	Spain	Thematic analysis	1) Internal and external barriers, 2) strategies to support nurse prescribing in the initial rollout and proposals for improvement, 3) factors linked to nurses’ satisfaction.	III A
Carey et al. (2010)	To explore the views of nurses, doctors, non-nurse prescribers and administrative staff on how nurse prescribing is being used in diabetes services.	A collective case study; a purposive sampling; interviews	10 nurse prescribers, 9 doctors, 9 administrative staff and 3 non-prescribing nurses.	United Kingdom	Thematic analysis	1) Organisation of care, 2) scope of practice, 3) role of policy changes, 4) team working.	III A
Chater et al. (2019)	To understand factors that influence community practitioner nurse prescriber’s prescribing behaviour.	The specific methodology was not indicated; purposive sampling; semi-structured interviews	20 nurse prescribers working in the community, with 2.5-20 years’ experience as a qualified prescriber.	United Kingdom	Thematic analysis	1) Knowledge and experience, 2) consultation and communication skills, 3) professional confidence and identity, 4) wanting the best outcome, 5) National Health Service (NHS) versus patient cost, 6) emotion-led decisions, 7) time allocation, 8) formulary access, 9) supporting environment for patient-centred care.	III A
Connor and McHugh (2019)	To explore how the role of non-medical prescribing in emergency departments throughout Ireland is developing and determine possible barriers to role expansion.	Interpretive phenomenological analysis; purposive sampling; interviews.	6 emergency department non-medical nurse prescribers.	Ireland	Thematic analysis	1) The process of role development, 2) changes in professional relationships, 3) nurses’ awareness of non-medical prescribing, 4) role progression, 5) the future of the role of the non-medical prescriber, 6) nursing management’s understanding of the role.	III B
Cousins and Donnell (2012)	1) To investigate the impact of becoming an independent prescriber for nurse practitioners in general practice. 2) Conﬁrming that independent prescribing increased job satisfaction. 3) Whether the extended role made a difference to potentials for stress in nurse practitioners.	The specific methodology was not indicated; purposive sampling; in-depth semi-structured interviews.	6 nurse practitioners who were also experienced independent prescribers. (They all have the qualifications of V300-independent and supplementary nurse prescribing.)	United Kingdom	Thematic analysis	1) Beneﬁts of nurse prescribing, 2) increased job demands, 3) support issues and lack of reward. Produced two overarching concepts: increased job satisfaction and work-related stress.	III B
Creedon et al. (2016)	To explore Nova Scotia nurse practitioners (with prescriptive authority) understanding of inappropriate prescribing and their experience of using a prescribing evaluation tool.	A descriptive phenomenology approach; purposive sampling; semi-structured interviews.	7 participants, experience as nurse practitioners with prescriptive authority ranged from 2 to 14 years.	Canada	Thematic analysis	1) Competence and conﬁdence, 2) understanding inappropriate prescribing, 3) consequences of inappropriate prescribing, 4) the role screening tools play in prescribing.	III B
Downer and Shepherd (2010)	To explore the experiences of district nurses prescribing as nurse independent prescribers across the West of Scotland.	A Heideggerian phenomenological approach; purposive sampling; individual interviews.	8 district independent nurse prescribers.	United Kingdom	Thematic analysis	1) Influences on prescribing practice; 2) benefits of nurse Prescribing; 3) difficulties with nurse prescribing	III B
Earle et al. (2011)	To look at these views and consider how the role can be developed further in light of non-medical prescribing in mental health settings.	Interpretive phenomenological analysis; purposive sampling; separate semi-structured interviews.	6 service users and 2 non-medical nurse prescribers trained in nurse prescribing.	United Kingdom	Thematic analysis	1. Service user interviews: 1) convenience, 2) the therapeutic relationship, 3) comparisons with standard care, 4) reduced stress, 5) information given, 6) choice and autonomy, 7) concerns, 8) suggested improvements. 2. Nurse prescriber interviews: 1) training, 2) the process of nurse prescribing; 3) concerns; 4) benefits, 5) the future of nurse prescribing, 6) the argument against prescribing.	III B
Fisher (2010)	To investigate the real world of nurse prescribing.	Ethnomethodology; purposive sampling; semi-structured interviews.	17 district nurses, 4 staff nurses, 2 pharmacists, and a general practitioner.	United Kingdom	Thematic analysis	Despite government efforts to encourage collaborative working, power relationships still play an important part in some areas of practice.	III B
Jones et al. (2007)	To explore the views of patients, mental health nurses and psychiatrists involved in mental health nurse supplementary prescribing.	The specific methodology was not indicated; purposive sampling; semi-structured interviews.	12 psychiatrists, 11 mental health nurses with prescribing authority, and 12 patients who had been prescribed psychiatric medication by a mental health nurse.	United Kingdom	Thematic analysis	1) Reaction, 2) barriers, 3) how to develop nurse prescribing.	III B
Lennon and Fallon (2018)	To explore the experiences of nurse prescribers in an acute service setting.	A descriptive phenomenological design; purposive sampling; semi-structured individual interviews.	11 current registered nurse prescribers from two acute hospitals.	Ireland	Thematic analysis	1) Enhanced patient care, 2) impact on the nurse as a prescriber, 3) the challenges of nurse prescribing.	III B
Lim et al. (2018)	To investigate and compare the experiences and perceptions of nurses and doctors in becoming prescribers.	Case-study; purposive sampling; Individual interviews.	16 junior doctors and 10 nurse practitioners who were novice prescribers at the time of the study.	New Zealand	Thematic analysis	1) Fear and anxiety when taking on prescribing responsibility; 2) the strategy of using a personal list of medicines to support safe practice; 3) how this list was expanded over time; 4) referring to senior colleagues in prescribing decision-making.	III A
Maddox et al. (2016)	To explore the factors inﬂuencing whether nurse and pharmacist non-medical nurse prescribers in community and primary care settings take responsibility for prescribing.	The specific methodology was not indicated; Purposive sampling; interviews.	15 non-medical nurse prescribers and 5 pharmacists working in primary and community care.	United Kingdom	Thematic analysis	1) Underpinning cautiousness, 2) competency, 3) role, 4) risk.	III A
Mahoney and Ladd (2010)	To gain understanding about nurse practitioners’ prescriptive decision making for geriatric patients with attention to pharmaceutical marketing inﬂuences.	Case-study; purposive sampling; semi-structured and open-ended group interviews.	14 nurse practitioners experienced prescribers from across the country.	United States	Thematic analysis	The key theme that emerged was that they were more than a prescriber. 1) Drug necessity or nondrug alternative? 2) Geriatric mantra: start low and go slow, 3) evidence-based practice—a dilemma, 4) the practice setting makes a difference, 5) multifaceted NP role, 6) there is a positive difference with NPs, 7) pharmaceutical marketing—information not education, 8) you have to care about drug costs, 9) resources for drug decision-making process.	III A
Pearson et al. (2020)	To investigate the experiences of registered prescribers and their perceptions of the enablers and barriers to registered prescribing and the value of this ﬂedgling role.	The specific methodology was not indicated; purposive and snowball sampling; semi-structured interviews.	16 registered nurse prescribers.	New Zealand	Thematic analysis	1) Ability to expand practice, 2) improving access to care, 3) importance of working in a collaborative team.	III B
Ross et al. (2014)	To explore the impact on the nurse–patient relationship in the mental health setting when the nurse is a prescriber.	A constructivist approach; purposive sampling; focus groups and interviews.	35 nurse practitioners, 3 pharmacist prescribers, 2 nurse managers, 7 consultant psychiatrists, a general practitioner and 9 clients.	United Kingdom	Framework matrix analysis	1) No change in the relationship, 2) change in the relationship, 3) client’s preferences.	III B
Scrafton et al. (2012)	To explore the experiences of secondary care nurse prescribers to establish how prescribing is employed and what its beneﬁts and disadvantages are perceived to be.	A phenomenological approach; convenience sampling; interviews.	6 nurse prescribers in secondary care.	United Kingdom	Thematic analysis	1) Motivations behind becoming a nurse prescriber; 2) beneﬁts and limitations of prescribing education and continuing professional development, 3) prescribing in practice.	III B
Stenner et al. (2010)	To explore the views of nurses and team members on the implementation of nurse prescribing in diabetes services.	A case study; purposive sampling; semi-structured interviews.	10 nurse prescribers, 9 physicians, 9 receptionists and 3 non-prescribing nurses.	United Kingdom	Thematic analysis	1) Initial problems resolved, 2) nurse supplementary prescribing and formulary changes, 3) good fit with existing roles and structures, 4) support structures, 5) acceptance.	III B
Stenner and Courtenay (2008)	To explore nurses’ views on the beneﬁts of adopting the role of prescribing for patients with acute and chronic pain.	The specific methodology was not indicated; purposive sampling; semi-structured interviews.	26 nurses qualiﬁed to prescribe medicines for patients in acute and chronic pain.	United Kingdom	Thematic analysis	Beneﬁts: 1) faster access to treatment, 2) improved safety, 3) appropriate prescribing and quality of care, 4) improved relations and communication with patients, 5) greater efﬁciency and cost effectiveness, 6) increased job satisfaction, 7) gaining knowledge through prescribing, 8) increased credibility and confidence to make recommendations.	III B
Watson (2021)	To explore nurse and midwife prescribers’ perception of educational preparation for the role and identify continuing professional development requirements to generate practitioner-based knowledge to inform education and research, policy and practice.	A hermeneutic phenomenological Approach; purposive sampling; individual semi-structured interviews.	8 advanced practitioners, 4 clinical midwife specialists and 4 clinical manager roles from two maternity hospitals, the areas where they were practicing were wide ranging including antenatal care, perinatal mental health, diabetes and in the obstetric emergency department.	Ireland	Thematic analysis	1) Educational preparation, 2) mentorship, 3) effect/contribution of education programme to practice, 4) continuing professional development.	III A
Weglicki et al. (2015)	To ascertain the aspirations, priorities and preferred mode of continuing professional development for non-medical prescribers.	A phenomenological approach; purposive sampling; semi-structured in-depth interviews and a focus group.	11 nurses, 3 physiotherapists, one pharmacist and one pharmacy technician, working in primary or secondary care settings in generalist or specialist advanced roles.	United Kingdom	Thematic analysis	1) Personal anxiety undermining conﬁdence to prescribe, 2) external barriers and other factors that exacerbate anxiety, 3) need for support identiﬁed. through coping strategies, 4) preferred mode or style of learning.	III B
Williams et al. (2018)	To explore general practitioners and nurse practitioners views on and experiences of prescribing antibiotics for respiratory tract infections (RTIs) in primary care Out-Of-Hours (OOH) services.	The specific methodology was not indicated; purposive sampling and snowball or chain sampling; semi-structured interviews.	15 general practitioners and 15 nurse practitioners working within primary care OOH services.	United Kingdom	Thematic analysis	1) Managing RTIs in primary care OOH, 2) factors influencing the decision to prescribe antibiotics in OOH.	III A
Wilson et al. (2021)	To determine the need for and value of nurse and midwife prescribing in Ireland as identified by these prescribers–the people most able to provide relevant insights and information.	An ethnographic–phenomenological design; purposive sampling; semi-structured interview.	10 nurse and 2 midwife prescribers, one was a new prescriber, the others had been prescribing for 2 to 10 years, working in hospital outpatient clinics and can prescribe medicinal products relative to their clinical practice areas.	Ireland	Thematic analysis	1) More than just writing prescriptions; 2) highly individualized evidence-based specialist care; 3) assured, timely and rapid accessibility to needed care; 4) health system and healthcare efficiency gains, 5) satisfaction with nurse/midwife prescriber services and 6) quality care improvements.	III B

Two central analytical themes are constructed: The Undervaluing of Nurse Prescribers and The Need for a Supportive System. Each theme is supported by several subthemes that represent the perceptions and voice concerns of prescribers. Collectively, they reflect the barriers nurse prescribers face in clinical practice and their need for support to develop full prescribing competency.

The Undervaluing of Nurse Prescribers

The Undervaluing of Nurse Prescribers is the first of the two central themes identified in the review. This theme represents a major barrier to the effective implementation of nurse prescribing and it encompasses three subthemes: Peer Misunderstanding and Deficits in Support, Patient Misconceptions and Distrust, and Physician Resistance and Practice Tensions.

Peer Misunderstanding and Deficits in Support

Nurse prescribing is a relatively new expansion of the nursing role in many healthcare settings. One Irish nurse prescriber working in an operating room described the wide range of responsibilities she undertook: “I prescribed analgesics and antibiotics mainly, but also tetanus and hepatitis vaccinations, morphine, eye drops and stains for eye examination, ointments, anaphylaxis treatment, lidocaine, and a long list actually. I did sutures, dressings, X-rays, referrals—anything needed by the patients” (Wilson et al., 2021, p. 5). According to Bowskill et al. (2013), nurse prescribers, particularly in primary and secondary care settings, often expected support from their nursing colleagues as they took on this expanded role. However, the literature also highlighted that this expectation is not always met. Canet-Vélez et al. (2023, pp. 4–7) reported that nurses in Spain described prescribing as “an increase in responsibility not supported by anything,” further noting that “colleagues still do not fully believe in the importance of nurse prescribing.” A similar sentiment was echoed in the United Kingdom, where a mental health nurse prescriber stated, “I thought it would be the doctors who were against me but it has actually been my peers” (Bowskill et al., 2013, p. 2082). These experiences suggest that misconceptions among nursing peers about the prescriber’s role are common. In one Irish emergency department, nurse prescribers were often asked by colleagues to prescribe outside their area of expertise, indicating a misunderstanding of the nurse prescriber’s scope and accountability:

I don’t think nursing colleagues understand the formality that goes into nurse prescribing and the accountability that goes into it and the amount of paperwork that is involved. I think they think we can just go off and prescribe whatever we want. (Connor & McHugh, 2019, p. 243)

Many nurse prescribers felt constrained by restrictive prescribing formularies and regulations. Studies by Canet-Vélez et al. (2023) and Chater et al. (2019) found that nurse prescribers often view the range of medications they are authorized to prescribe as “very restrictive and incomplete.” For example, Bowskill et al. (2013) found that nurse prescribers in secondary care settings frequently identified medications they needed to prescribe that were not included in their formulary. In addition, Lennon and Fallon (2018) found that nurse prescribers in Ireland reported their prescribing parameters were “much stricter compared to physicians” (p. e530).

Additionally, nurse prescribers frequently reported a widespread lack of both social and managerial support, which included not only deficits in affirmation and appraisal support from their managers but also practical and structural barriers, such as insufficient resources to carry out prescribing duties. Connor and McHugh (2019, pp. 243–244) documented the experience of an Irish emergency department nurse prescriber who felt that her managers “never met their needs and appreciated the benefits of nurse prescribing,” and further stated that management “didn’t support me because the Emergency Department was too busy.” In the United States, Mahoney and Ladd (2010) also reported that limited human resources and a shortage of trained nurse prescribers impeded managerial support; for instance, job rotation programs intended for nurse prescribers were ultimately not implemented due to staffing constraints. Similarly, nurse prescribers in Canada and Ireland described practice settings in which they were effectively isolated in their roles, lacking both practical support—such as adequate staffing—and essential infrastructure, including dedicated workspace to carry out prescribing tasks (Connor & McHugh, 2019; Mahoney & Ladd, 2010). One Canadian nurse prescriber recalled being “the only nurse practitioner within a huge facility (485 beds)” (Creedon et al., 2016, p. 26), and hospital-based nurse prescribers reported lacking even a dedicated office or quiet space for prescribing work:

There is no office so there is nowhere you can go and sit and open the laptop and say right for the next two hours I won’t do this. . . you don’t have anywhere to call your own. (Lennon & Fallon, 2018, p. 530)

Several studies reported that many nurse prescribers felt overburdened by the dual demands of nursing care and prescribing responsibilities, particularly in the absence of sufficient remuneration (Chater et al., 2019; Lennon & Fallon, 2018; Pearson et al., 2020). For instance, Lennon and Fallon (2018, p. 531) cited an acute-care nurse prescriber who remarked, “doing extra work for no extra cost. . . It is not an incentive to do it either.” This lack of financial recognition left some feeling undervalued. As one nurse prescriber put it:

It was never about remuneration; it was really about value, but actually when you add such an advanced tool, why can’t it be about remuneration? No matter how you look at it, it is more time that you spend around that patient and making sure the patient’s safe. (Pearson et al., 2020, p. 5)

Patient Misconceptions and Distrust

In the study conducted by Ross et al. (2014), it was evident that patients lacked awareness of the nurse prescriber’s role. Some patients confused nurse prescribers with physicians, even addressing nurses as “doctors” after a consultation (Ross et al., 2014, p. 6). In the United Kingdom, the studies conducted by Earle et al. (2011) and Williams et al. (2018) found that certain patients have voiced distrust in prescriptions from nurses, believing that only physicians can provide proper prescriptions. Such misconceptions can place nurse prescribers in a vulnerable position, especially when their treatment decisions differ from physicians. Williams et al. (2018, p. 798) reported that one United States nurse practitioner with a prescribing role described feeling that patients suspected she was withholding antibiotics “because I’m a nurse and that if they saw a doctor they would get them instead.” This suggests that some patients may perceive differences in prescribing decisions as being influenced by a distrust of the nurse prescriber's professional role, rather than the clinical judgment behind the decision.

Physician Resistance and Practice Tensions

Tensions can also arise between nurse prescribers and physicians over-prescribing authority. Traditionally, physicians have been the primary decision-makers for patient prescriptions, and some doctors are hesitant to share or cede this responsibility. Specialist nurses in the United Kingdom who were also nurse prescribers have noted the delicate balance between exercising prescribing autonomy and maintaining professional courtesy toward physicians, as one nurse described:

One practice was quite dismissive and didn’t want nurses interfering with their (doctor’s) patients. . . You (nurse prescribers) need their agreement really because it is politeness as it is their patient. (Bowskill et al., 2013, p. 2082)

Differences in clinical decision-making between nurse prescribers and physicians can undermine effective teamwork in patient care and negatively impact outcomes. Stenner and Courtenay (2008) described a nurse prescriber’s concern about general practitioners prescribing higher doses of controlled medications, which might be better initiated at lower doses. While the higher dose may initially boost patient confidence, it can also lead to side effects. Such discrepancies in practice can erode patient trust in nurse prescribers, undermine their prescribing behavior, hinder collaboration, and ultimately compromise patient outcomes.

Often when the general practitioners initiate a controlled drug, say slow-release morphine or a fentanyl patch, they will initiate it at quite a high dose. . . and then you have lost the patient’s confidence in that particular drug, even though it may be better for the patient at a lower dose. (Stenner & Courtenay, 2008, p. 31)

Mahoney and Ladd (2010) noted that nurse prescribers and physicians came from different professional perspectives, which sometimes led to conflicting views on treatment protocols. Specifically, nurses tended to emphasize evidence-based practice and patient-centered care, while some physicians adhered strictly to established protocols. A nurse practitioner in the United States explained how this conflict can leave nurse prescribers feeling “hog-tied” if a physician insists on a particular regimen despite evidence to the contrary:

. . . docs . . . have speciﬁc protocols that they want to stick with. So, you can end up with a problem where you know evidence-based, something is better and you can bring that to your doc, but if he’s solid in what he or she wants to prescribe, and that’s how they want to manage their patients; you’re hog-tied with that too. (Mahoney & Ladd, 2010, p. 21)

The Need for a Supportive System

The Need for a Supportive System is the second of the two central themes identified in the review. There are three subthemes under this central theme: Improve Continuous and Standardized Prescribing Education, Improve Multi-disciplinary Collaboration, and Enhance Supervision.

Improve Continuous and Standardized Prescribing Education

Studies have found that to minimize prescribing errors and maintain safe practice, nurse prescribers need to continually update their knowledge (Bradley et al., 2007; Weglicki et al., 2015). Several studies reported that many nurses experienced limited access to ongoing training and professional development related to prescribing (Connor & McHugh, 2019; Downer & Shepherd, 2010; Maddox et al., 2016; Pearson et al., 2020; Stenner et al., 2010). Nurse prescribers frequently expressed the need for more continuous education in pharmacology and prescribing skills. For example, Abuzour et al. (2018a) reported that one United Kingdom nurse, after attending an intensive multi-week prescribing course, found the in-depth system-based knowledge gained to be very beneficial. Similarly, Pearson et al. (2020, p. 6) cited a New Zealand nurse prescriber who emphasized the value of a post-qualification pharmacology training program, stating that it improved how she educated patients about their medications, including the purpose, mechanism, and potential side effects of drugs. In the same vein, Watson (2021) reported that nurse prescribers in Ireland acknowledged that additional training in pharmacology and prescribing competencies would enhance their practice. Beyond pharmacology, knowledge of legal and ethical issues in prescribing is also essential. As one United Kingdom nurse specialist pointed out:

From a legal aspect, it would be useful knowing where you stood, should there be a mistake made. . . (Weglicki et al., 2015, p. 228)

However, nurse prescribers observed inconsistencies in the educational requirements for prescribing qualifications. A nurse prescriber argued that the credit requirements for nurse prescribing programs should be standardized nationwide to ensure all prescribers receive equivalent training:

48 credits at level 3 and some of the others are a lot less credits and to me, a nurse prescribing course should be equal throughout the country, to gain the same qualification. (Scrafton et al., 2012, p. 2047)

Improve Multi-disciplinary Collaboration

Canet-Vélez et al. (2023) emphasized that clear protocols and clinical practice guidelines provided a foundation for collaborative prescribing and helped align nurse prescribers’ decisions with those of the broader healthcare team. For example, Wilson et al. (2021) highlighted that establishing consistent prescribing guidelines promoted greater consistency between nurses and physicians. Nonetheless, Maddox et al. (2016) reported that nurse prescribers sometimes felt “uneasy” or “uncertain” when guidelines were unclear or when they faced complex decisions independently.

Creedon et al. (2016) found that nurse prescribers often sought support from colleagues when managing challenging cases. In hospital settings, they valued a collaborative, no-blame culture that enabled them to freely ask physicians or senior nurses for advice. For example, one independent nurse prescriber described feeling “very comfortable” working in a team where she could easily consult others without fear of blame:

It (the collaborative culture) is a no-blame culture but it’s also a very supportive area, so if you’re not sure about something then you just ask or you look it up or you refer to trust policy. . . I do feel very comfortable. (Abuzour et al., 2018a, p. 5)

In community settings, nurse prescribers may rely on a wider multidisciplinary team—such as pharmacists (Bradley et al., 2007; Creedon et al., 2016; Maddox et al., 2016) or other specialist nurses (Bradley et al., 2007)—for guidance. Physicians, as experienced prescribers, also serve as important resources; nurse prescribers commonly discuss prescribing decisions with doctors to ensure patient safety. This collaborative consultation acted as a “safety net” for nurses’ prescribing practices, as highlighted by several studies (Canet-Vélez et al., 2023; Carey et al., 2010; Chater et al., 2019; Downer & Shepherd, 2010; Lim et al., 2018; Pearson et al., 2020; Williams et al., 2018). As one nurse prescriber explained:

. . .attention to detail is required and if I have a problem, I will take it to my collaborative practice partner to discuss. I work in a collaborative team, so I don’t work in isolation. . . it’s always well to have a colleague around for advice. (Creedon et al., 2016, p. 27)

Enhance Supervision

Several studies reported that nurse prescribers felt most confident when managing cases they had previously encountered (Abuzour et al., 2018a; Chater et al., 2019; Creedon, 2016; Maddox et al., 2016). In contrast, several studies reported that unfamiliar medications or complex clinical conditions often caused apprehension among nurse prescribers (Canet-Vélez et al., 2023; Lennon & Fallon, 2018; Lim et al., 2018; Maddox et al., 2016). Ensuring a clearly defined scope of practice—particularly for new prescribers—is essential, as an overly broad scope of independent prescribing may heighten the risk of errors in drug selection or dosing. One nurse prescriber found that initially focusing on a limited formulary helped build confidence and competence:

I’ve tried to focus on those few [drugs] so I’ve become familiar with those medications, and I feel almost comfortable with my knowledge of those medications. I don’t think it would be a good idea as a new prescriber to prescribe across the whole range. (Bradley et al., 2007, p. 605)

Regular auditing and feedback from experienced prescribers were also cited as crucial for safe practice (Lennon & Fallon, 2018; Scrafton et al., 2012; Williams et al., 2018; Wilson et al., 2021). Audits—reviews of a nurse prescriber’s decisions and documentation—help ensure compliance with clinical guidelines and patient safety standards. Implementing formal audit systems for new nurse prescribers is advisable to bolster safe prescribing (Stenner et al., 2010). One nurse prescriber described how auditing in her early prescribing years alleviated her initial fears:

I had a bit of fear at first, but because of the audits, I knew I gave good safe and needed care. I knew my prescriptions were correctly written and correct for the patients. (Wilson et al., 2021, p. 4)

Despite the reported benefits of audits and mentorship, several studies noted that resources for such oversight were often limited. Pearson et al. (2020, p. 8) observed that physicians who might provide supervision were frequently “time-poor,” and that there were too few experienced nurse prescribers available to mentor newcomers. One nurse prescriber remarked, “there are not enough nurse practitioners around to supervise and provide the ongoing support required and mentoring that RN prescribers need” (Pearson et al., 2020, p. 8). These shortages point to a need for institutional commitment to provide adequate support personnel and time for supervision.

Discussion

This review synthesized the barriers faced by nurses with prescriptive authority and the types of support needed to help them achieve full competency in their prescribing roles. The findings were organized into two overarching analytical themes: “The Undervaluing of Nurse Prescribers” and “The Need for a Supportive System.” The first theme, “The Undervaluing of Nurse Prescribers,” highlights the multifaceted barriers nurse prescribers would encounter. The second theme, “The Need for a Supportive System,” underscores the supportive structures required by nurse prescribers to enable effective practice. The following discussion examines the root causes of the challenges nurse prescribers face and the rationale for their supposed support for optimal practices.

Undervalued Professional Role of Nurse Prescribers

Our findings indicate that nurse prescribers often struggle for recognition as independent professionals. Historical power imbalances in healthcare and longstanding stereotypes about nursing contribute to this issue. Since the inception of modern nursing, nurses have frequently been viewed as assistants to physicians, with roles limited to routine bedside tasks. These deep-rooted misconceptions persist in the public and among some healthcare colleagues (López-Verdugo et al., 2021; Teresa-Morales et al., 2022), which can erode trust in nurse prescribers’ capabilities. Patients may doubt a nurse’s prescription or prefer a doctor’s opinion, reflecting a lack of understanding of nurses’ qualifications to prescribe.

There is also ambiguity within the nursing profession itself regarding the prescriber’s role. Internationally, there is no uniform standard for nurse prescriber qualifications—debate continues over whether prescribing authority should be limited to advanced practice specialists or extended to generalist nurses (ICN, 2021). This lack of clarity can leave nursing peers uncertain about nurse prescribers’ scope of practice, hindering effective collaboration. As seen in our results, insufficient support from colleagues can increase work-related stress for nurse prescribers and isolate them in practice (Canet-Vélez et al., 2023; Pearson et al., 2020).

Nurse prescribing also challenges traditional physician–nurse hierarchies, which can lead to friction. Physicians have historically been viewed as the primary decision-makers, and some may be reluctant to share prescribing responsibilities. This dynamic can manifest as resistance or dismissiveness toward nurse prescribers (Nuttall, 2018; Pritchard, 2018). By blurring professional boundaries, nurse prescribing requires a renegotiation of roles that some healthcare teams find difficult. Clear delineation of responsibilities and mutual respect are necessary to mitigate these conflicts (Brault et al., 2014). For instance, establishing agreed-upon protocols or formularies for nurse prescribing can help clarify what nurse prescribers can do independently (ICN, 2021; Pritchard, 2018).

The Need for a Supportive System

The review also underscores the critical need for supportive systems to enable nurse prescribers to function effectively. One key area is Continuing Professional Development (CPD). Many nurse prescribers in the included studies reported inadequate support for ongoing education and training in prescribing, a concern noted in both earlier and more recent literature (Downer & Shepherd, 2010; Maddox et al., 2016; Pearson et al., 2020). Keeping knowledge up to date through CPD is essential for maintaining prescribing competence and confidence (ICN, 2021). Access to regular training and development opportunities—whether through workshops, advanced courses, or e-learning—has been linked to greater confidence among nurse prescribers (Seck et al., 2024). In fact, some countries mandate a certain amount of CPD for nurse prescribers to retain their credentials (Hanson & Cahill, 2019; ICN, 2021; Schober, 2019).

Another common barrier is the restrictive scope of practice under which many nurse prescribers operate. As in our results, nurse prescribers frequently feel limited by narrow formularies and stricter prescribing rules compared to physicians. The scope of nurse prescribing varies widely across jurisdictions due to differing legislation and health system structures (ICN, 2021). In some places, nurses can prescribe only a short list of medications or must work under physician supervision, which can hamper their efficiency and sense of autonomy. Professional bodies like the ICN (2021) recommend that nurse prescribers be actively involved in advocacy and policy-making to appropriately expand their prescribing scope within familiar areas of practice and standardize formularies. Broadening the legislative and regulatory framework for nurse prescribing would allow nurses to utilize their full potential in patient care.

Beyond education and scope of practice, systemic and institutional support plays a pivotal role. Novice nurse prescribers often benefit from the oversight of experienced clinicians as they build decision-making skills (Lim et al., 2018). Our review highlighted that while audits and mentorship from physicians or senior nurses can enhance safety and confidence, over-reliance on physician oversight may inadvertently perpetuate power imbalances. A supportive system should strive for a balance: providing nurse prescribers with guidance and feedback (for example, through regular prescription audits and mentorship programs) without undermining their autonomy. Establishing formal support structures—such as mentorship networks or dedicated supervisory roles for experienced nurse prescribers—could be one way to achieve this balance.

Recommendations

Based on our review findings, we offer the following actionable recommendations to guide the development and strengthening of nurse prescribing:

Address Structural and Organizational Barriers

The review highlights that barriers to nurse prescribing are often external and systemic. Healthcare leaders and policymakers should work to address organizational constraints, such as limited resources, unclear policies, and lack of support, to facilitate safe and effective prescribing practices.

Empower Nurse Prescribers to Lead and Advocate

Nurse prescribers should be involved in policy development and leadership discussions to ensure their experiences inform decision-making. Sharing research findings and success stories can help policymakers and stakeholders better understand the nurse prescriber’s role, thereby garnering support from health administrators and professional bodies (Fox et al., 2022; ICN, 2021). Increased awareness and understanding among medical colleagues, health administrators, and the public are also crucial. By advocating for supportive legislation, organizational policies, and educational frameworks, stakeholders can help remove the obstacles nurse prescribers face and strengthen the practice of nurse prescribing.

Conduct Qualitative Research in Emerging Contexts

All the studies in our review originated from Western developed countries, particularly the UK. The absence of studies from such developing regions underscores the global disparity in nurse prescribing development and highlights a significant research gap. In countries where nurse prescribing is still emerging or yet to be implemented, gathering evidence from the perspective of nurses is essential. Future qualitative studies in these settings could explore nurses’ concerns and the underlying factors contributing to any hesitation in adopting prescribing roles. Such insights may inform targeted strategies to support the introduction and development of nurse prescribing, potentially accelerating its adoption in new contexts (Almotairy et al., 2023; Babaei et al., 2022).

Limitations

This review has several limitations. First, because all included studies were conducted in Western developed countries (with a majority from the United Kingdom), the findings may not be directly applicable to regions with different healthcare systems or where nurse prescribing is in earlier stages of development. The lack of studies from other parts of the world likely reflects where nurse prescribing has been implemented and studied, but it also points to gaps in the literature. Second, most of the included articles were of good quality (Grade B) rather than high quality (Grade A). While all studies met a minimum quality threshold for inclusion, the relative scarcity of top-tier qualitative research on this topic suggests that more robust, in-depth studies are needed in the future to strengthen the evidence base.

Conclusion

Nurse prescribers encounter significant external barriers in exercising their prescribing authority. These include misunderstandings or lack of support from peers, patients, and physicians, as well as regulatory restrictions and insufficient institutional support. Our review underscores the need for strong supportive systems—spanning education, policy, and practice environments—to empower nurse prescribers. These conclusions are drawn largely from studies in Western developed countries, and we have outlined strategies to overcome the common challenges identified. Moving forward, concerted efforts by stakeholders and administrators are required to raise awareness of the value of nurse prescribing and to implement supportive policies and infrastructure. Through collaborative efforts and enhanced support, nurse prescribing can be more fully integrated into healthcare delivery, ultimately improving patient access to care and health outcomes.

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Footnotes

Acknowledgements

Not applicable.

ORCID iDs

Jiaxi Xu

Aimei Mao

Ethical Considerations

Ethics approval was not required for this systematic review and thematic synthesis.

Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Author Contributions

Jiaxi XU: Conceptualization; Data Curation (lead); Formal Analysis (lead); Methodology; Writing – original draft preparation; Writing – review and editing. Aimei MAO: Supervision; Writing – review and editing (equal). Lu QI: Data Curation; Formal Analysis

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Jiaxi Xu, MN, RN is a master’s student at Kiang Wu Nursing College of Macau, Macau SAR, China

Lu Qi, MN, RN is a master’s student at Kiang Wu Nursing College of Macau, Macau SAR, China

Aimei Mao, PhD, MSN, RN is an Associate Professor at Kiang Wu Nursing College of Macau, Macau SAR, China.

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