Required MaterialLawler, E. E. (2017). Reinventing talent manage.docx

Required Material
Lawler, E. E. (2017). Reinventing talent management:
Principles and practices for the new world of work. Retrieved
from ProQuest, Ebook Central in the Trident Online Library.
RBL Group. (2015). Overview of the Competency Model [Video
file]. Retrieved
from https://www.youtube.com/watch?v=9BdjdgySzxE.
Sanghi, S. (2016). Chapter 1: Introduction to competency
mapping. In The Handbook of Competency Mapping:
Understanding, Designing, and Implementing Competency
Models in Organizations (pp. 1-25). Thousand Oaks, California:
Sage Publications. Retrieved from EBSCO in the Trident Online
Library.
Sanghi, S. (2016). Chapter 3: Competency-based applications.
The Handbook of Competency Mapping: Understanding,
Designing, and Implementing Competency Models in
Organizations (pp. 49-76). Thousand Oaks, California: Sage
Publications. Retrieved from EBSCO in the Trident Online
Library.
(If you are interested in learning more about competency
models and mapping, read other chapters in this book.)
RESEARCH - EDUCATION
Improving prescribing practices: A pharmacist-led educational
intervention for nurse practitioner students
Jennifer A. Sabatino, PharmD, BCACP (Clinical Pharmacist)1,
Maria C. Pruchnicki, PharmD, BCPS, BCACP, CLS
(Associate Professor)2, Alexa M. Sevin, PharmD, BCACP
(Assistant Professor)2, Elizabeth Barker, PhD, CNP,
FAANP, FACHE, FNAP, FAAN, FNP-BC (Professor Emeritus

of Clinical Nursing)3, Christopher G. Green, PharmD
(Specialty Practice Pharmacist)4, & Kyle Porter, MAS (Senior
Consulting Research Statistician)5
1Department of Pharmacy, Memorial Hospital Medication
Therapies Center, Marysville, Ohio
2Division of Pharmacy Practice and Science, The Ohio State
University College of Pharmacy, Columbus, Ohio
3College of Nursing, The Ohio State University, Columbus,
Ohio
4Department of Pharmacy, The Ohio State University Wexner
Medical Center, Columbus, Ohio
5Center for Biostatistics, The Ohio State University, Columbus,
Ohio
Keywords
Pharmacotherapy; education; prescriptions;
students; pharmacists; nurse practitioner;
advanced practice nurse.
Correspondence
Maria C. Pruchnicki, PharmD, BCPS, BCACP,
CLS, Division of Pharmacy Practice and Science,
The Ohio State University College of Pharmacy,
500 West 12th Avenue, Columbus, OH 43210.
Tel: 614-292-1363; Fax: 614-292-1335; E-mail:
[email protected]
Received: 22 May 2016;

accepted: 6 January 2017
doi: 10.1002/2327-6924.12446
Previous presentations: Poster presentation at
the American Pharmacists Association Annual
Meeting, March 2014, Orlando, Florida.
Encore poster presentation at the Ohio
Pharmacists Association 136th Annual Meeting,
April 2014, Columbus, Ohio.
Podium presentation at the Ohio Pharmacy
Resident Conference, May 2014, Ada, Ohio.
Encore podium presentation at the Celebration
of Educational Scholarship “Advances in Health
Sciences Education” at The Ohio State
University College of Medicine, November
2014, Columbus, Ohio.
Encore poster presentation at the American
Pharmacists Association Annual Meeting,
March 2015, San Diego, California.

Abstract
Background and purpose: To assess impact of a pharmacist-led
educational
intervention on family nurse practitioner (FNP) students’
prescribing skills, per-
ception of preparedness to prescribe, and perception of
pharmacist as collabora-
tor.
Method: Prospective pre–post assessment of a 14-week
educational interven-
tion in an FNP program in the spring semester of 2014. Students
participated in
an online module of weekly patient cases and prescriptions
emphasizing legal
requirements, prescription accuracy, and appropriate therapy. A
pharmacist fa-
cilitator provided formative feedback on students’ submissions.
Participants com-
pleted a matched assessment on prescription writing before and
after the module,
and a retrospective postsurvey then presurvey to collect
perceptions.
Conclusion: There was significant improvement in performance
on error iden-
tification and demonstration of prescription elements from
preassessment to
postassessment (+17%, p < .001). The mean performance on
both assessments
was less than the 70% passing score. Students reported
significant positive
changes in perceptions, including all statements regarding their
preparedness to
prescribe and those addressing willingness to collaborate with
pharmacists.
Implications for practice: Formative education on prescribing

enhanced stu-
dents’ understanding of safe and effective medication use with
improved recog-
nition and avoidance of prescribing errors, although it did not
result in compe-
tency. Exposure to pharmacist expertise in this area may
encourage collaboration
in practice.
Introduction
Like physicians, nurse practitioners have prescriptive
authority within the scope of their practice (Newhouse
et al., 2011). In the 2009–2010 American Association
of Nurse Practitioners Sample Survey of 13,562 nurse
practitioners, 97.6% reported prescribing medications to
patients, averaging 22 prescriptions per day in full-time
practice (Goolsby, 2011). However, studies have shown
that new prescribers often do not feel adequately prepared
(Hilmer, Seale, Le Couteur, Crampton, & Liddle, 2009;
Rauniar, Roy, Das, Bhandari, & Bhattacharya, 2008).
Evaluation of errors in various settings has determined
248 Journal of the American Association of Nurse Practitioners
29 (2017) 248–254
C©2017 American Association of Nurse Practitioners
J. A. Sabatino et al. Improving prescribing practices
that most preventable adverse drug events occur as the
result of errors made in the prescribing stage (Thomsen,
Winterstein, Søndergaard, Haugbølle, & Melander, 2007).
A study by Kuo, Phillips, Graham, and Hickner (2008)

reported that 70% of errors made in primary care physi-
cians’ offices were prescribing errors. Medication selection
and dose were the most common types of prescribing er-
ror, with the most error-prone factors being incorrect drug
selection, contraindications such as medication allergies,
incorrect dosing, and including insufficient information
on the prescription. In the study, pharmacists were re-
sponsible for preventing the errors from reaching patients
the majority of the time, consistent with their training
and expertise. However, pharmacists may not be routinely
utilized to their potential by nurse practitioners. In the
Nurse Practitioner Sample Survey, the reported frequency
of pharmacist consultation by nurse practitioners was
weekly (30.3%), monthly (29.9%), one to two times per
year (29.7%), daily (6.9%), and never (3.2%, Goolsby,
2011). Yet incorporation of pharmacists into the patient
care team has been identified as a healthcare strategy with
positive outcomes for patients, including improvement in
clinical markers such as hemoglobin A1c, LDL cholesterol,
and blood pressure and reduction in adverse drug events
(Chisholm-Burns et al., 2010).
This is the first study to assess the impact of a pharmacist
educating nurse practitioner students on the elements of
appropriate, safe, and complete prescription writing with
weekly online patient cases. We hypothesized that the
incorporation of a pharmacist in nurse practitioner stu-
dent learning could improve preparedness to prescribe as
well as encourage collaboration with pharmacists as part
of an interprofessional healthcare team. The purpose of
this study was to evaluate an existing educational inter-
vention in the family nurse practitioner (FNP) curriculum
to assess the impact on: (a) students’ clinical and proce-
dural accuracy of prescribing, (b) students’ perception of
preparedness to prescribe, and (c) students’ perception of
a pharmacist as a collaborator.

Methods
This study was a prospective pre–post assessment of a
14-week educational intervention designed to improve
technical and clinical aspects of prescribing of FNP stu-
dents. This research was determined to be exempt by The
Ohio State University Institutional Review Board.
Educational intervention
In an effort to expand interprofessional learning beyond
experiential educational settings, our faculty–practitioner
team developed and implemented a pharmacist-directed
prescribing intervention, delivered as a 14-week online
education module for FNP students. The intention of the
program was for a clinical pharmacist to educate students
at The Ohio State University (Ohio State) and provide
them longitudinal practice for appropriate prescribing
habits, including the identification and correction of the
factors commonly associated with prescribing errors. The
technical aspect of appropriate prescribing requires the
provider to include all necessary elements for a legally
complete and accurate prescription. Clinical prescribing
errors have a greater potential to cause patient harm and
involve medication choice and dosing with respect to indi-
cation as well as patient specific factors including concur-
rent medications or comorbidities (Velo & Minuz, 2009).
FNP students enrolled in a clinical practicum during
spring semester 2014 participated in an online mod-
ule delivered using the course management platform at
Ohio State (Carmen; [email protected]). Each week,
the pharmacist facilitator posted a patient case to the
discussion board and students were asked to review a

corresponding prescription for accuracy and appropriate-
ness or to generate a prescription for the patient. The
weekly exercises emphasized legal requirements and ac-
curacy (technical elements) as well as patient safety
considerations (clinical elements). A summary of the
various clinical prescribing issues addressed in the weekly
exercises is provided in Table 1. Students were asked to
identify any errors in the prescription, provide three pa-
tient counseling points for the medication prescribed, and
then demonstrate a correct prescription for the patient.
Each week, the pharmacist posted a response that pro-
vided formative feedback on errors commonly identified
and/or missed by the students, addressed any miscon-
ceptions from the class, and answered additional ques-
tions that had been raised by the class. The exercises were
graded as satisfactory/unsatisfactory based on student
participation.
Assessments
Prescribing skills before and after the didactic interven-
tion were assessed using an original assessment tool, de-
veloped with input from Ohio State’s University Center for
Advancement of Teaching (a campus-wide teaching cen-
ter). The assessment was reviewed for face validity and
content validity by the investigator team and the collabo-
rating educational consultants, respectively. Students were
given limited time (20 min) to complete each assessment
in order to simulate the limited decision-making and pre-
scribing time that is available in practice. Research as-
sessments were administered at predetermined times dur-
ing the study protocol, specifically before and after the
14-week online educational intervention. All students
249

Improving prescribing practices J. A. Sabatino et al.
Table 1 Description of clinical prescribing issues addressed in
intervention
Case number Clinical issues addressed
1 Prescribing a medication without a clinical indication
Medication allergy to prescribed agent
Medication dosed incorrectly
Quantity prescribed does not cover duration of
treatment
Drug–drug interaction
2 Topical formulation prescribed when oral formulation
indicated
Ambiguous directions contributing to inaccurate dosing
Refills inappropriate as patient should be reevaluated
3 Drug–disease state interaction
Maximum safe daily dose exceeded
4 Drug–age interaction
Drug–disease state interaction

Alternative drug choice more appropriate based on
patient-specific factors
5 Inappropriate dosage form for pediatric patient
Dose inaccurate based on patient weight
6 Additional medication not indicated based on
therapeutic goals
Maximize current therapy before adding additional
agent
Dose too high
7 Drug contraindicated in pregnant patient
Stepwise dose increase more appropriate
agent

9 Ambiguous directions contributing to inaccurate dosing
10 Dosing of medication inappropriate due to narrow
therapeutic index
11 Patient requires additional work up before prescribing
12 Medication allergy to prescribed agent
13 Prescribing medication without accompanying
prescription for supplies
guidelines
Drug choice and cost considerations
Ambiguous directions making accurate dosing
challenging
were required to complete the assessments as part of the
course requirements, but only those consenting to the re-
search had their responses included in the study. All stu-
dents enrolled in the course were eligible to participate in
the study.
The preassessment consisted of questions regarding four

prescription cases and a demographic survey. Cases 1–3
asked the students to identify any clinical or technical
errors in the corresponding prescriptions. Case 4 prompted
the students to write a prescription on the prescription
blank provided. Demographic questions targeted baseline
characteristics of participants: age, gender, primary lan-
guage, prior exposure to pharmacists or pharmacy stu-
dents, and the number of prescriptions written prior to the
activity.
The postassessment included the identical prescription
cases and a retrospective postsurvey then presurvey,
which was used to collect information on the students’
perceived preparedness to prescribe, willingness to collab-
orate with pharmacists, and perception of the pharmacist
as the educator. The retrospective postsurvey then presur-
vey differs from the more common presurvey then post-
survey design in that respondents complete both surveys at
the conclusion of the intervention. This is done to address
the fact that respondents who have little experience with
a subject prior to an educational intervention are unable
to accurately assess their perceptions of the subject on a
presurvey (Rockwell & Kohn, 1989). This tool was chosen
to allow the students to self-report their perceived change
over time using the same scale for pre- and postresponses
and without the potential bias introduced by a traditional
pretest. The 11 perception questions or statements were
rated on a 4-point Likert scale ranging from “strongly dis-
agree” to “strongly agree” and from “highly unlikely” to
“highly likely,” as appropriate. In answering the postsur-
vey then presurvey, students were asked to provide a re-
sponse to each question or statement first with what their
perceptions were at the point of conclusion of the educa-
tional intervention and then think back to the point prior
to starting the educational intervention.

Data analysis
Errors to be identified in the assessment were grouped
by type (i.e., technical or clinical), level of impact (i.e., pa-
tient harm, inconvenience, or minimal impact), and cat-
egory of error (i.e., directions, dosing, patient elements,
medication elements, etc.). Four practitioner investigators
individually assigned the groupings of each error and then
met to achieve consensus on the final groupings prior to
administration of the preassessment. The prescription as-
sessment was scored for each student as the percentage of
errors correctly identified/avoided, both overall and within
each specific category of errors. Competency was assessed
by comparing the overall score to 70%, a standard passing
score for a graduate nursing program. Improvement from
preassessment to postassessment was measured as the in-
crease in percentage correct for each category. Preassess-
ment, postassessment, and change scores are reported as
median with interquartile range (first quartile to third
quartile) across the 26 students. Nonparametric Wilcoxon
250
sign rank tests were applied to the change scores to as-
sess within-student improvement overall and within er-
ror type, severity of impact, and category using SAS 9.3
(Cary, NC). For the retrospective postsurvey then presur-
vey, responses were reported as frequency and percent-
age. The primary questions measuring student perceptions
by signed rank test were assessed with the null hypothesis
being zero change. No adjustments were made for multiple

comparisons.
Results
All of the 30 FNP students enrolled in the course
consented for the study. Of those, two students were
ineligible due to nonattendance at the administration of
the preassessment and two more students withdrew from
the course before the postassessment was administered,
resulting in a final participant pool of 26. The majority of
participants were female, aged 25–30, spoke English as a
primary language, and were registered nurses. Work ex-
perience was the most common exposure to pharmacists
or pharmacy students (Table 2).
Prescribing ability
The overall performance on the prescription cases
from the preassessment to postassessment showed
improvement with a median increase of 17% (p <
.001); the overall median score for the postassess-
ment was 57% (Table 3). Identification of errors
and demonstration of clinical and technical pre-
scription elements from preassessment to postassess-
ment also improved (p < .001). Individually, two of
26 students (8%) had an overall score greater than 70%
on the postassessment, compared to zero students on the
preassessment.
The performance on technical elements was consis-
tently greater than the performance on clinical elements,
with legal requirements of controlled substance pre-
scribing showing the least improvement from preassess-
ment to postassessment. When errors to be identified
were grouped by potential patient impact, the improve-
ment was significant from preassessment to postassess-

ment across all three levels of potential impact: harm
(p < .001), inconvenience (p < .001), and minimal
impact (p = .01). Improvement from preassessment
to postassessment on categories of errors was signif-
icant for those pertaining to directions, dosing, pa-
tient elements, prescriber elements, medication elements,
and other required elements (see Table 3). Only the
change in performance from preassessment to postassess-
ment on error-prone abbreviations was not significant
(p = .17).
Table 2 Demographic characteristics of 26 family nurse
practitioner
studentsa
N (%)
Age
<24 years 3 (12)
25–30 years 13 (50)
31–35 years 6 (23)
>35 years 4 (15)
Gender
Female 22 (85)
Primary language
English 25 (96)
Other 1 (4)

Credentials earned
RN 20 (77)
BSN 13 (50)
Other 1 (4)
Exposure to pharmacists or pharmacy students
Work experience 13 (50)
Part of a required course 10 (38)
Experiential rotations 7 (27)
Part of an elective course 4 (15)
Volunteer experience 3 (12)
No previous exposure 2 (8)
Student organization 2
Family member or close friend who is a pharmacist
Yes 9 (35)
Number of prescriptions written
<10 prescriptions 1 (4)
11–50 prescriptions 8 (31)

>100 prescriptions 5 (19)
aThe Ohio State University, 2014.
Perceptions
On the retrospective postsurvey then presurvey, the
students reported statistically significant increases in the
perception ratings on all statements that addressed their
preparedness to prescribe. Following the educational
intervention, there was an increase in agreement that
classroom education and clinical rotations prepared the
students for prescribing (p = .03 and p = .04, respectively)
and that nurse practitioners should have formal training
on writing prescriptions (p = .03). The largest positive
change was seen in response to the statement, “I feel
completely prepared to prescribe medications” (p < .001).
Students who reported having written fewer prescrip-
tions prior to the online prescribing module showed a
significantly larger positive change from preassessment
to postassessment in response to the statement, “I feel
completely prepared to prescribe medications” (p = .01).
A similar trend was seen on all statements that ad-
dressed the pharmacist as the educator, as students agreed
that a pharmacist-led prescribing activity is helpful in
251
Table 3 Family nurse practitioner student performancea on
assessmentsb

Median (IQR) Preassessment Postassessment Changec p-Value
Overall 38% (30–47%) 57% (49–66%) 17% (11–23%) <.001
Type of error
Clinical 27% (18–36%) 45% (36–55%) 16% (5–23%) <.001
Technical 44% (36–60%) 68% (60–76%) 20% (12–28%) <.001
Patient impact
Harm 30% (22–39%) 48% (35–57%) 15% (4–26%) <.001
Inconvenience 50% (39–67%) 72% (67–78%) 25% (11–33%)
<.001
Minimal impact 33% (17–50%) 50% (33–83%) 17% (0–33%)
.01
Category of error
Directions 19% (13–38%) 44% (25–50%) 19% (0–38%) .003
Dosing 25% (0–50%) 50% (25–50%) 25% (0–50%) .02
Error-prone abbreviations 25% (0–25%) 25% (0–50%) 0% (0–
25%) .17
Patient elements 80% (60–100%) 100% (80–100%) 10% (0–
40%) .004
Prescriber elements 40% (40–60%) 80% (80–100%) 40% (20–
60%) <.001

Medication elements 50% (38–63%) 63% (63–75%) 13% (13–
25%) <.001
Other required elements 33% (17–50%) 67% (50–83%) 17% (0–
50%) <.001
aPerformance measured as percentage of possible errors
identified for each category and reported as median and
interquartile range (IQR: first and third
quartiles) across all 26 students.
bThe Ohio State University, 2014.
cChange reported as median of individual differences calculated
from preassessment to postassessment for each of 26 students.
preparing nurse practitioners to prescribe (p = .01) and
that pharmacists are qualified to educate nurse practition-
ers on prescribing (p = .03). Significant positive changes
in perception were also demonstrated on three out of five
statements that addressed their willingness to collaborate
with a pharmacist in practice (Figure 1).
Discussion
In our study, a pharmacist-led educational intervention
resulted in significant improvement in prescribing abilities
for FNP students, almost entirely across the spectrum of
abilities assessed. The prescription cases in the assessment
highlighted examples of factors most commonly associated
with prescribing errors, including dosing and other med-
ication elements. Students demonstrated significant im-
provement in their ability to identify/avoid these errors,
suggesting that instruction in both the technical and clin-
ical components of prescribing supported appropriate and
safe prescription writing. In particular, there was signifi-

cant improvement in identification and avoidance of er-
rors that were categorized as having potential for patient
Figure 1 Family nurse practitioner student perceptions regarding
collaboration with pharmacist in practices.
252
harm. In general, improvements on items related to tech-
nical proficiency were greater than those related to clinical
performance, with the exception being the legal require-
ments of controlled substance prescribing which remained
very low on both assessments.
Unfortunately, the overall postassessment average
remained below the standard passing score for a graduate
nursing program, and a >30% error rate would be far
from acceptable in patient care. This suggests that longitu-
dinal, online learning activities are effective in improving
prescribing abilities; however this single module was not
sufficient in itself. Our results are consistent with findings
of a published systematic review that examined the impact
of various therapeutic tutorials and workshops on new
practitioner knowledge and prescribing skill (Kamarudin,
Penm, Chaar, & Moles, 2013). In the included studies, a
range of interventions were studied with many showing
improvements in prescribing performance, including those
incorporated into structured academic curricula. However,
subjects were most commonly medical interns and the
intervention was typically a single session without the
opportunity for prescribing practice or formative feedback.
The study in the review most similar to our research

utilized an 8-week intervention for medical students com-
prised of four 1-h physician and pharmacist-led tutorials
and eight 1-h practical sessions on prescribing (Sandilands
et al., 2011). Students were given a pretest and posttest
to assess incidence of prescribing errors and self-reported
confidence. Those investigators demonstrated improved
performance and confidence, but also with continued
prescribing errors made on the posttest and overall mean
posttest performance �70%.
To build upon previously studied interventions, we
designed our online prescribing module to provide both
longer-term (longitudinal) practice and formative feed-
back on prescribing. Students specifically had regular
practice with repeated exposure to technical elements
of prescription writing (which showed the greatest im-
provements), while each clinical element was addressed
only a maximum of three times over 14 weeks (Table 1).
The importance of practice as a research-based learning
strategy is well-known. In the book How Learning Works:
7 Research Based Principles for Smart Teaching, authors note
that both sufficient quantity of practice and practice
over time (accumulating practice) are needed (Ambrose,
Bridges, DiPietro, Lovett, & Norman, 2010, pp. 133–136).
Typically, instructors and students alike underestimate
how much practice is needed. Therefore, additional cases
focused on clinical components related to patient factors,
errors with potential for patient harm, error-prone abbre-
viations, and legal requirements of controlled substance
prescribing would likely have benefited the study partici-
pants, and may have resulted in greater change. A strategy
for continuing the online exercises throughout the FNP
didactic curriculum could be explored and studied further.
The retrospective postsurvey then presurvey examined

the impact of the intervention as perceived by the stu-
dents, with the greatest significant increase in percep-
tion rating from preassessment to postassessment on the
statement, “I feel completely prepared to prescribe.” Af-
ter completion of the educational intervention, 81% of
students agreed that they were completely prepared to
prescribe medications, compared to only 27% of students
who agreed with the statement prior to completion of the
educational intervention. Those students who had writ-
ten fewer prescriptions prior to the intervention showed
a significantly larger positive change on the survey state-
ment regarding feeling completely prepared to prescribe.
Though the general perception of preparedness is not con-
sistent with our objective results, an expected benefit of
targeted feedback is to help students more accurately dis-
cern change in learning behaviors and assess their own
progress. The “nonpassing” postassessment scores may
suggest that students did not review all of the posted feed-
back from the weekly exercises. Online posting of the
feedback with student-directed review cuts down on the
time investment required from the pharmacist facilitator
and allows for broader application with limited resources.
Kamarudin et al. suggest that prescriber feedback in the
form of “provider letters” is a cost-effective teaching strat-
egy (Kamarudin et al., 2013), but the heavy reliance on
student independence and student inexperience may have
limited the learning gains in our format.
Despite the poor prescribing performance on the pre-
assessment, students ranked highly their previous instruc-
tion for prescribing (i.e., prescribing activities in previ-
ous classes and during clinical rotations, provided before
this educational intervention). This was unexpected, as
we believed students would recognize that they were not
highly prepared at the time of the preassessment. How-
ever, students were never given the results of, or solu-

tions to, the preassessments in an effort to prevent re-
call bias. Therefore, the students did not seem to clearly
differentiate between the respective impact of the studied
educational module versus prior classroom education and
clinical rotations. Module enhancements such as provid-
ing the students with the objective scores on the preassess-
ments and postassessments, conducting formal review ses-
sions, and/or having the weekly feedback being facilitated
as asynchronous online discussions should be considered
to encourage students to rework cases, consider alterna-
tives, and self-assess.
Ninety-six percent of students agreed with the state-
ment, “Involving a pharmacist in the prescribing pro-
cess would result in better patient outcomes” with no
change from the preassessment to postassessment ratings.
253
Although the students also strongly agreed that pharma-
cists should be involved in prescribing, there was actually
the least change in perception on the statement, “How
likely are you to consult a pharmacist for help writing
a prescription?” (69% on the preassessment vs. 77% on
the postassessment). Though positive, this trend was not
found to be significant. A possible explanation for this
is that the students may not have anticipated requiring
help writing a prescription after the educational interven-
tion (i.e., expecting they were now proficient). Percep-
tions regarding collaboration with a pharmacist in prac-
tice prior to the educational intervention may have been
confounded by consistent promotion of interprofessional

collaboration by nurse practitioner educators within the
curriculum.
Though the tools utilized were not validated, a major
strength of the study is that the assessments were designed
and implemented collaboratively between pharmacist and
nurse practitioner researchers and educational/assessment
experts. The use of the retrospective postsurvey then
presurvey was intended to reduce response shift bias as
a threat to internal validity (Rockwell & Kohn, 1989).
Self-reporting is generally vulnerable to bias as learners
may respond in the way that they believe their educator
wants them to. Another limitation specific to the retro-
spective design of the survey was the potential inaccuracy
of student recall when responding to the statements based
on what their perceptions were prior to the activity.
Finally, the study was limited by the small population
included, especially in that the results may not be directly
applicable to teaching and learning strategies for other
professional students. Repeating the study with the use
of a control group may more accurately demonstrate the
impact of the intervention.
Future directions include evaluation of the duration and
timing of the educational intervention in FNP student cur-
ricula, to optimize outcomes and also to identify the point
at which incorporation of pharmacist-provided prescribing
practice would be most meaningful, for example, in didac-
tic versus experiential coursework. Broadening the appli-
cation to prescriber training in other disciplines should also
be explored.
Conclusions
Formative education on appropriate prescribing, includ-
ing the opportunity for longitudinal practice, enhances

preparedness of future nurse practitioner prescribers.
Well-prepared prescribers would be expected to make
fewer prescribing errors, leading to fewer preventable ad-
verse drug events and reduction in delays initiating or op-
timizing drug therapy. Exposure of the nurse practitioner
students to pharmacist expertise in this area during train-
ing may also encourage future collaboration in practice,
which could further reduce errors and impact outcomes
for patients.
Acknowledgments
The authors wish to thank Stephanie Rohdieck and
Teresa Johnson of The Ohio State University Center for
the Advancement of Teaching. Jennifer Sabatino, Maria
Pruchnicki, Alexa Sevin, Elizabeth Barker, and
Christopher Green developed the instrument and
performed data analysis; Jennifer Sabatino administered
the instrument, collected data, and wrote the initial draft
of the article; Kyle Porter provided statistical analysis; all
authors developed the research project and revised the
article for final submission. There is no funding to disclose.
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254
RESEARCH - EDUCATION

Improving prescribing practices: A pharmacist-led educational
intervention for nurse practitioner students
Jennifer A. Sabatino, PharmD, BCACP (Clinical Pharmacist)1,
Maria C. Pruchnicki, PharmD, BCPS, BCACP, CLS
(Associate Professor)2, Alexa M. Sevin, PharmD, BCACP
(Assistant Professor)2, Elizabeth Barker, PhD, CNP,
FAANP, FACHE, FNAP, FAAN, FNP-BC (Professor Emeritus
of Clinical Nursing)3, Christopher G. Green, PharmD
(Specialty Practice Pharmacist)4, & Kyle Porter, MAS (Senior
Consulting Research Statistician)5
1Department of Pharmacy, Memorial Hospital Medication
Therapies Center, Marysville, Ohio
2Division of Pharmacy Practice and Science, The Ohio State
University College of Pharmacy, Columbus, Ohio
3College of Nursing, The Ohio State University, Columbus,
Ohio
4Department of Pharmacy, The Ohio State University Wexner
Medical Center, Columbus, Ohio
5Center for Biostatistics, The Ohio State University, Columbus,
Ohio
Keywords
Pharmacotherapy; education; prescriptions;
students; pharmacists; nurse practitioner;
advanced practice nurse.
Correspondence
Maria C. Pruchnicki, PharmD, BCPS, BCACP,
CLS, Division of Pharmacy Practice and Science,
The Ohio State University College of Pharmacy,

500 West 12th Avenue, Columbus, OH 43210.
Tel: 614-292-1363; Fax: 614-292-1335; E-mail:
[email protected]
Received: 22 May 2016;
accepted: 6 January 2017
doi: 10.1002/2327-6924.12446
Previous presentations: Poster presentation at
the American Pharmacists Association Annual
Meeting, March 2014, Orlando, Florida.
Encore poster presentation at the Ohio
Pharmacists Association 136th Annual Meeting,
April 2014, Columbus, Ohio.
Podium presentation at the Ohio Pharmacy
Resident Conference, May 2014, Ada, Ohio.
Encore podium presentation at the Celebration
of Educational Scholarship “Advances in Health
Sciences Education” at The Ohio State
University College of Medicine, November

2014, Columbus, Ohio.
Encore poster presentation at the American
Pharmacists Association Annual Meeting,
March 2015, San Diego, California.
Abstract
Background and purpose: To assess impact of a pharmacist-led
educational
intervention on family nurse practitioner (FNP) students’
prescribing skills, per-
ception of preparedness to prescribe, and perception of
pharmacist as collabora-
tor.
Method: Prospective pre–post assessment of a 14-week
educational interven-
tion in an FNP program in the spring semester of 2014. Students
participated in
an online module of weekly patient cases and prescriptions
emphasizing legal
requirements, prescription accuracy, and appropriate therapy. A
pharmacist fa-
cilitator provided formative feedback on students’ submissions.
Participants com-
pleted a matched assessment on prescription writing before and
after the module,
and a retrospective postsurvey then presurvey to collect
perceptions.
Conclusion: There was significant improvement in performance
on error iden-
tification and demonstration of prescription elements from
preassessment to
postassessment (+17%, p < .001). The mean performance on

both assessments
was less than the 70% passing score. Students reported
significant positive
changes in perceptions, including all statements regarding their
preparedness to
prescribe and those addressing willingness to collaborate with
pharmacists.
Implications for practice: Formative education on prescribing
enhanced stu-
dents’ understanding of safe and effective medication use with
improved recog-
nition and avoidance of prescribing errors, although it did not
result in compe-
tency. Exposure to pharmacist expertise in this area may
encourage collaboration
in practice.
Introduction
Like physicians, nurse practitioners have prescriptive
authority within the scope of their practice (Newhouse
et al., 2011). In the 2009–2010 American Association
of Nurse Practitioners Sample Survey of 13,562 nurse
practitioners, 97.6% reported prescribing medications to
patients, averaging 22 prescriptions per day in full-time
practice (Goolsby, 2011). However, studies have shown
that new prescribers often do not feel adequately prepared
(Hilmer, Seale, Le Couteur, Crampton, & Liddle, 2009;
Rauniar, Roy, Das, Bhandari, & Bhattacharya, 2008).
Evaluation of errors in various settings has determined
248 Journal of the American Association of Nurse Practitioners
29 (2017) 248–254
C©2017 American Association of Nurse Practitioners

that most preventable adverse drug events occur as the
result of errors made in the prescribing stage (Thomsen,
Winterstein, Søndergaard, Haugbølle, & Melander, 2007).
A study by Kuo, Phillips, Graham, and Hickner (2008)
reported that 70% of errors made in primary care physi-
cians’ offices were prescribing errors. Medication selection
and dose were the most common types of prescribing er-
ror, with the most error-prone factors being incorrect drug
selection, contraindications such as medication allergies,
incorrect dosing, and including insufficient information
on the prescription. In the study, pharmacists were re-
sponsible for preventing the errors from reaching patients
the majority of the time, consistent with their training
and expertise. However, pharmacists may not be routinely
utilized to their potential by nurse practitioners. In the
Nurse Practitioner Sample Survey, the reported frequency
of pharmacist consultation by nurse practitioners was
weekly (30.3%), monthly (29.9%), one to two times per
year (29.7%), daily (6.9%), and never (3.2%, Goolsby,
2011). Yet incorporation of pharmacists into the patient
care team has been identified as a healthcare strategy with
positive outcomes for patients, including improvement in
clinical markers such as hemoglobin A1c, LDL cholesterol,
and blood pressure and reduction in adverse drug events
(Chisholm-Burns et al., 2010).
This is the first study to assess the impact of a pharmacist
educating nurse practitioner students on the elements of
appropriate, safe, and complete prescription writing with
weekly online patient cases. We hypothesized that the
incorporation of a pharmacist in nurse practitioner stu-
dent learning could improve preparedness to prescribe as

well as encourage collaboration with pharmacists as part
of an interprofessional healthcare team. The purpose of
this study was to evaluate an existing educational inter-
vention in the family nurse practitioner (FNP) curriculum
to assess the impact on: (a) students’ clinical and proce-
dural accuracy of prescribing, (b) students’ perception of
preparedness to prescribe, and (c) students’ perception of
a pharmacist as a collaborator.
Methods
This study was a prospective pre–post assessment of a
14-week educational intervention designed to improve
technical and clinical aspects of prescribing of FNP stu-
dents. This research was determined to be exempt by The
Ohio State University Institutional Review Board.
Educational intervention
In an effort to expand interprofessional learning beyond
experiential educational settings, our faculty–practitioner
team developed and implemented a pharmacist-directed
prescribing intervention, delivered as a 14-week online
education module for FNP students. The intention of the
program was for a clinical pharmacist to educate students
at The Ohio State University (Ohio State) and provide
them longitudinal practice for appropriate prescribing
habits, including the identification and correction of the
factors commonly associated with prescribing errors. The
technical aspect of appropriate prescribing requires the
provider to include all necessary elements for a legally
complete and accurate prescription. Clinical prescribing
errors have a greater potential to cause patient harm and
involve medication choice and dosing with respect to indi-
cation as well as patient specific factors including concur-

rent medications or comorbidities (Velo & Minuz, 2009).
FNP students enrolled in a clinical practicum during
spring semester 2014 participated in an online mod-
ule delivered using the course management platform at
Ohio State (Carmen; [email protected]). Each week,
the pharmacist facilitator posted a patient case to the
discussion board and students were asked to review a
corresponding prescription for accuracy and appropriate-
ness or to generate a prescription for the patient. The
weekly exercises emphasized legal requirements and ac-
curacy (technical elements) as well as patient safety
considerations (clinical elements). A summary of the
various clinical prescribing issues addressed in the weekly
exercises is provided in Table 1. Students were asked to
identify any errors in the prescription, provide three pa-
tient counseling points for the medication prescribed, and
then demonstrate a correct prescription for the patient.
Each week, the pharmacist posted a response that pro-
vided formative feedback on errors commonly identified
and/or missed by the students, addressed any miscon-
ceptions from the class, and answered additional ques-
tions that had been raised by the class. The exercises were
graded as satisfactory/unsatisfactory based on student
participation.
Assessments
Prescribing skills before and after the didactic interven-
tion were assessed using an original assessment tool, de-
veloped with input from Ohio State’s University Center for
Advancement of Teaching (a campus-wide teaching cen-
ter). The assessment was reviewed for face validity and
content validity by the investigator team and the collabo-
rating educational consultants, respectively. Students were
given limited time (20 min) to complete each assessment

in order to simulate the limited decision-making and pre-
scribing time that is available in practice. Research as-
sessments were administered at predetermined times dur-
ing the study protocol, specifically before and after the
14-week online educational intervention. All students
249
Table 1 Description of clinical prescribing issues addressed in
intervention
Case number Clinical issues addressed
1 Prescribing a medication without a clinical indication
Medication allergy to prescribed agent
Medication dosed incorrectly
Quantity prescribed does not cover duration of
treatment
Drug–drug interaction
2 Topical formulation prescribed when oral formulation
indicated
Ambiguous directions contributing to inaccurate dosing

Maximum safe daily dose exceeded
4 Drug–age interaction
Drug–disease state interaction
5 Inappropriate dosage form for pediatric patient
6 Additional medication not indicated based on
therapeutic goals
agent
Dose too high
7 Drug contraindicated in pregnant patient

agent
9 Ambiguous directions contributing to inaccurate dosing
10 Dosing of medication inappropriate due to narrow
therapeutic index
11 Patient requires additional work up before prescribing
12 Medication allergy to prescribed agent
13 Prescribing medication without accompanying
prescription for supplies
guidelines
Drug choice and cost considerations
Ambiguous directions making accurate dosing
challenging

were required to complete the assessments as part of the
course requirements, but only those consenting to the re-
search had their responses included in the study. All stu-
dents enrolled in the course were eligible to participate in
the study.
The preassessment consisted of questions regarding four
prescription cases and a demographic survey. Cases 1–3
asked the students to identify any clinical or technical
errors in the corresponding prescriptions. Case 4 prompted
the students to write a prescription on the prescription
blank provided. Demographic questions targeted baseline
characteristics of participants: age, gender, primary lan-
guage, prior exposure to pharmacists or pharmacy stu-
dents, and the number of prescriptions written prior to the
activity.
The postassessment included the identical prescription
cases and a retrospective postsurvey then presurvey,
which was used to collect information on the students’
perceived preparedness to prescribe, willingness to collab-
orate with pharmacists, and perception of the pharmacist
as the educator. The retrospective postsurvey then presur-
vey differs from the more common presurvey then post-
survey design in that respondents complete both surveys at
the conclusion of the intervention. This is done to address
the fact that respondents who have little experience with
a subject prior to an educational intervention are unable
to accurately assess their perceptions of the subject on a
presurvey (Rockwell & Kohn, 1989). This tool was chosen
to allow the students to self-report their perceived change
over time using the same scale for pre- and postresponses
and without the potential bias introduced by a traditional
pretest. The 11 perception questions or statements were

rated on a 4-point Likert scale ranging from “strongly dis-
agree” to “strongly agree” and from “highly unlikely” to
“highly likely,” as appropriate. In answering the postsur-
vey then presurvey, students were asked to provide a re-
sponse to each question or statement first with what their
perceptions were at the point of conclusion of the educa-
tional intervention and then think back to the point prior
to starting the educational intervention.
Data analysis
Errors to be identified in the assessment were grouped
by type (i.e., technical or clinical), level of impact (i.e., pa-
tient harm, inconvenience, or minimal impact), and cat-
egory of error (i.e., directions, dosing, patient elements,
medication elements, etc.). Four practitioner investigators
individually assigned the groupings of each error and then
met to achieve consensus on the final groupings prior to
administration of the preassessment. The prescription as-
sessment was scored for each student as the percentage of
errors correctly identified/avoided, both overall and within
each specific category of errors. Competency was assessed
by comparing the overall score to 70%, a standard passing
score for a graduate nursing program. Improvement from
preassessment to postassessment was measured as the in-
crease in percentage correct for each category. Preassess-
ment, postassessment, and change scores are reported as
median with interquartile range (first quartile to third
quartile) across the 26 students. Nonparametric Wilcoxon
250

sign rank tests were applied to the change scores to as-
sess within-student improvement overall and within er-
ror type, severity of impact, and category using SAS 9.3
(Cary, NC). For the retrospective postsurvey then presur-
vey, responses were reported as frequency and percent-
age. The primary questions measuring student perceptions
by signed rank test were assessed with the null hypothesis
being zero change. No adjustments were made for multiple
comparisons.
Results
All of the 30 FNP students enrolled in the course
consented for the study. Of those, two students were
ineligible due to nonattendance at the administration of
the preassessment and two more students withdrew from
the course before the postassessment was administered,
resulting in a final participant pool of 26. The majority of
participants were female, aged 25–30, spoke English as a
primary language, and were registered nurses. Work ex-
perience was the most common exposure to pharmacists
or pharmacy students (Table 2).
Prescribing ability
The overall performance on the prescription cases
from the preassessment to postassessment showed
improvement with a median increase of 17% (p <
.001); the overall median score for the postassess-
ment was 57% (Table 3). Identification of errors
and demonstration of clinical and technical pre-
scription elements from preassessment to postassess-
ment also improved (p < .001). Individually, two of
26 students (8%) had an overall score greater than 70%
on the postassessment, compared to zero students on the
preassessment.

The performance on technical elements was consis-
tently greater than the performance on clinical elements,
with legal requirements of controlled substance pre-
scribing showing the least improvement from preassess-
ment to postassessment. When errors to be identified
were grouped by potential patient impact, the improve-
ment was significant from preassessment to postassess-
ment across all three levels of potential impact: harm
(p < .001), inconvenience (p < .001), and minimal
impact (p = .01). Improvement from preassessment
to postassessment on categories of errors was signif-
icant for those pertaining to directions, dosing, pa-
tient elements, prescriber elements, medication elements,
and other required elements (see Table 3). Only the
change in performance from preassessment to postassess-
ment on error-prone abbreviations was not significant
(p = .17).
Table 2 Demographic characteristics of 26 family nurse
practitioner
studentsa
N (%)
Age
<24 years 3 (12)
25–30 years 13 (50)
31–35 years 6 (23)
>35 years 4 (15)
Gender

Female 22 (85)
Primary language
English 25 (96)
Other 1 (4)
Credentials earned
RN 20 (77)
BSN 13 (50)
Other 1 (4)
Exposure to pharmacists or pharmacy students
Work experience 13 (50)
Part of a required course 10 (38)
Experiential rotations 7 (27)
Part of an elective course 4 (15)
Volunteer experience 3 (12)
No previous exposure 2 (8)
Student organization 2
Family member or close friend who is a pharmacist
Yes 9 (35)

Number of prescriptions written
<10 prescriptions 1 (4)
>100 prescriptions 5 (19)
aThe Ohio State University, 2014.
Perceptions
On the retrospective postsurvey then presurvey, the
students reported statistically significant increases in the
perception ratings on all statements that addressed their
preparedness to prescribe. Following the educational
intervention, there was an increase in agreement that
classroom education and clinical rotations prepared the
students for prescribing (p = .03 and p = .04, respectively)
and that nurse practitioners should have formal training
on writing prescriptions (p = .03). The largest positive
change was seen in response to the statement, “I feel
completely prepared to prescribe medications” (p < .001).
Students who reported having written fewer prescrip-
tions prior to the online prescribing module showed a
significantly larger positive change from preassessment
to postassessment in response to the statement, “I feel
completely prepared to prescribe medications” (p = .01).
A similar trend was seen on all statements that ad-
dressed the pharmacist as the educator, as students agreed
that a pharmacist-led prescribing activity is helpful in

251
Table 3 Family nurse practitioner student performancea on
assessmentsb
Median (IQR) Preassessment Postassessment Changec p-Value
Overall 38% (30–47%) 57% (49–66%) 17% (11–23%) <.001
Type of error
Clinical 27% (18–36%) 45% (36–55%) 16% (5–23%) <.001
Technical 44% (36–60%) 68% (60–76%) 20% (12–28%) <.001
Patient impact
Harm 30% (22–39%) 48% (35–57%) 15% (4–26%) <.001
Inconvenience 50% (39–67%) 72% (67–78%) 25% (11–33%)
<.001
Minimal impact 33% (17–50%) 50% (33–83%) 17% (0–33%)
.01
Category of error
Directions 19% (13–38%) 44% (25–50%) 19% (0–38%) .003
Dosing 25% (0–50%) 50% (25–50%) 25% (0–50%) .02
Error-prone abbreviations 25% (0–25%) 25% (0–50%) 0% (0–

25%) .17
Patient elements 80% (60–100%) 100% (80–100%) 10% (0–
40%) .004
Prescriber elements 40% (40–60%) 80% (80–100%) 40% (20–
60%) <.001
Medication elements 50% (38–63%) 63% (63–75%) 13% (13–
25%) <.001
Other required elements 33% (17–50%) 67% (50–83%) 17% (0–
50%) <.001
aPerformance measured as percentage of possible errors
identified for each category and reported as median and
interquartile range (IQR: first and third
quartiles) across all 26 students.
bThe Ohio State University, 2014.
cChange reported as median of individual differences calculated
from preassessment to postassessment for each of 26 students.
preparing nurse practitioners to prescribe (p = .01) and
that pharmacists are qualified to educate nurse practition-
ers on prescribing (p = .03). Significant positive changes
in perception were also demonstrated on three out of five
statements that addressed their willingness to collaborate
with a pharmacist in practice (Figure 1).
Discussion
In our study, a pharmacist-led educational intervention
resulted in significant improvement in prescribing abilities
for FNP students, almost entirely across the spectrum of

abilities assessed. The prescription cases in the assessment
highlighted examples of factors most commonly associated
with prescribing errors, including dosing and other med-
ication elements. Students demonstrated significant im-
provement in their ability to identify/avoid these errors,
suggesting that instruction in both the technical and clin-
ical components of prescribing supported appropriate and
safe prescription writing. In particular, there was signifi-
cant improvement in identification and avoidance of er-
rors that were categorized as having potential for patient
Figure 1 Family nurse practitioner student perceptions regarding
collaboration with pharmacist in practices.
252
harm. In general, improvements on items related to tech-
nical proficiency were greater than those related to clinical
performance, with the exception being the legal require-
ments of controlled substance prescribing which remained
very low on both assessments.
Unfortunately, the overall postassessment average
remained below the standard passing score for a graduate
nursing program, and a >30% error rate would be far
from acceptable in patient care. This suggests that longitu-
dinal, online learning activities are effective in improving
prescribing abilities; however this single module was not
sufficient in itself. Our results are consistent with findings
of a published systematic review that examined the impact
of various therapeutic tutorials and workshops on new
practitioner knowledge and prescribing skill (Kamarudin,

Penm, Chaar, & Moles, 2013). In the included studies, a
range of interventions were studied with many showing
improvements in prescribing performance, including those
incorporated into structured academic curricula. However,
subjects were most commonly medical interns and the
intervention was typically a single session without the
opportunity for prescribing practice or formative feedback.
The study in the review most similar to our research
utilized an 8-week intervention for medical students com-
prised of four 1-h physician and pharmacist-led tutorials
and eight 1-h practical sessions on prescribing (Sandilands
et al., 2011). Students were given a pretest and posttest
to assess incidence of prescribing errors and self-reported
confidence. Those investigators demonstrated improved
performance and confidence, but also with continued
prescribing errors made on the posttest and overall mean
posttest performance �70%.
To build upon previously studied interventions, we
designed our online prescribing module to provide both
longer-term (longitudinal) practice and formative feed-
back on prescribing. Students specifically had regular
practice with repeated exposure to technical elements
of prescription writing (which showed the greatest im-
provements), while each clinical element was addressed
only a maximum of three times over 14 weeks (Table 1).
The importance of practice as a research-based learning
strategy is well-known. In the book How Learning Works:
7 Research Based Principles for Smart Teaching, authors note
that both sufficient quantity of practice and practice
over time (accumulating practice) are needed (Ambrose,
Bridges, DiPietro, Lovett, & Norman, 2010, pp. 133–136).
Typically, instructors and students alike underestimate
how much practice is needed. Therefore, additional cases
focused on clinical components related to patient factors,
errors with potential for patient harm, error-prone abbre-

viations, and legal requirements of controlled substance
prescribing would likely have benefited the study partici-
pants, and may have resulted in greater change. A strategy
for continuing the online exercises throughout the FNP
didactic curriculum could be explored and studied further.
The retrospective postsurvey then presurvey examined
the impact of the intervention as perceived by the stu-
dents, with the greatest significant increase in percep-
tion rating from preassessment to postassessment on the
statement, “I feel completely prepared to prescribe.” Af-
ter completion of the educational intervention, 81% of
students agreed that they were completely prepared to
prescribe medications, compared to only 27% of students
who agreed with the statement prior to completion of the
educational intervention. Those students who had writ-
ten fewer prescriptions prior to the intervention showed
a significantly larger positive change on the survey state-
ment regarding feeling completely prepared to prescribe.
Though the general perception of preparedness is not con-
sistent with our objective results, an expected benefit of
targeted feedback is to help students more accurately dis-
cern change in learning behaviors and assess their own
progress. The “nonpassing” postassessment scores may
suggest that students did not review all of the posted feed-
back from the weekly exercises. Online posting of the
feedback with student-directed review cuts down on the
time investment required from the pharmacist facilitator
and allows for broader application with limited resources.
Kamarudin et al. suggest that prescriber feedback in the
form of “provider letters” is a cost-effective teaching strat-
egy (Kamarudin et al., 2013), but the heavy reliance on
student independence and student inexperience may have
limited the learning gains in our format.

Despite the poor prescribing performance on the pre-
assessment, students ranked highly their previous instruc-
tion for prescribing (i.e., prescribing activities in previ-
ous classes and during clinical rotations, provided before
this educational intervention). This was unexpected, as
we believed students would recognize that they were not
highly prepared at the time of the preassessment. How-
ever, students were never given the results of, or solu-
tions to, the preassessments in an effort to prevent re-
call bias. Therefore, the students did not seem to clearly
differentiate between the respective impact of the studied
educational module versus prior classroom education and
clinical rotations. Module enhancements such as provid-
ing the students with the objective scores on the preassess-
ments and postassessments, conducting formal review ses-
sions, and/or having the weekly feedback being facilitated
as asynchronous online discussions should be considered
to encourage students to rework cases, consider alterna-
tives, and self-assess.
Ninety-six percent of students agreed with the state-
ment, “Involving a pharmacist in the prescribing pro-
cess would result in better patient outcomes” with no
change from the preassessment to postassessment ratings.
253
Although the students also strongly agreed that pharma-
cists should be involved in prescribing, there was actually
the least change in perception on the statement, “How
likely are you to consult a pharmacist for help writing
a prescription?” (69% on the preassessment vs. 77% on

the postassessment). Though positive, this trend was not
found to be significant. A possible explanation for this
is that the students may not have anticipated requiring
help writing a prescription after the educational interven-
tion (i.e., expecting they were now proficient). Percep-
tions regarding collaboration with a pharmacist in prac-
tice prior to the educational intervention may have been
confounded by consistent promotion of interprofessional
collaboration by nurse practitioner educators within the
curriculum.
Though the tools utilized were not validated, a major
strength of the study is that the assessments were designed
and implemented collaboratively between pharmacist and
nurse practitioner researchers and educational/assessment
experts. The use of the retrospective postsurvey then
presurvey was intended to reduce response shift bias as
a threat to internal validity (Rockwell & Kohn, 1989).
Self-reporting is generally vulnerable to bias as learners
may respond in the way that they believe their educator
wants them to. Another limitation specific to the retro-
spective design of the survey was the potential inaccuracy
of student recall when responding to the statements based
on what their perceptions were prior to the activity.
Finally, the study was limited by the small population
included, especially in that the results may not be directly
applicable to teaching and learning strategies for other
professional students. Repeating the study with the use
of a control group may more accurately demonstrate the
impact of the intervention.
Future directions include evaluation of the duration and
timing of the educational intervention in FNP student cur-
ricula, to optimize outcomes and also to identify the point
at which incorporation of pharmacist-provided prescribing
practice would be most meaningful, for example, in didac-

tic versus experiential coursework. Broadening the appli-
cation to prescriber training in other disciplines should also
be explored.
Conclusions
Formative education on appropriate prescribing, includ-
ing the opportunity for longitudinal practice, enhances
preparedness of future nurse practitioner prescribers.
Well-prepared prescribers would be expected to make
fewer prescribing errors, leading to fewer preventable ad-
verse drug events and reduction in delays initiating or op-
timizing drug therapy. Exposure of the nurse practitioner
students to pharmacist expertise in this area during train-
ing may also encourage future collaboration in practice,
which could further reduce errors and impact outcomes
for patients.
Acknowledgments
The authors wish to thank Stephanie Rohdieck and
Teresa Johnson of The Ohio State University Center for
the Advancement of Teaching. Jennifer Sabatino, Maria
Pruchnicki, Alexa Sevin, Elizabeth Barker, and
Christopher Green developed the instrument and
performed data analysis; Jennifer Sabatino administered
the instrument, collected data, and wrote the initial draft
of the article; Kyle Porter provided statistical analysis; all
authors developed the research project and revised the
article for final submission. There is no funding to disclose.
References
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Norman, M. K.

(2010). Chapter 5: What kinds of practice and feedback enhance
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Herrier, R. N.,
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team members
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628.
254
Shedding Light on Nurse Practitioner
Prescribing
Elissa Ladd, PhD, FNP-BC, and Alex Hoyt, PhD, RN
The Jo166
ABSTRACT
Transparency initiatives in society are growing. In the realm of
prescribing, recent
federal, state, and private initiatives are shedding light on
health care provider practice
and payments. These transparency initiatives commonly include
information on nurse
practitioners. Recently implemented federal and state Sunshine
laws are discussed.
Also, the newly released Medicare Part D data, which include
nurse practitioner
identified information, are described in the context of the
federal data release as well as
the news outlets that are utilizing this watershed of information
to inform the public
on health care provider practice.
Keywords: Medicare Part D, nurse practitioner, pharmaceutical
industry, prescribing,
Sunshine laws, transparency
� 2016 Elsevier, Inc. All rights reserved.
e live in a transparent world, whether we
like it or not. In recent years, society,
Wboth explicitly and implicitly, has moved

toward increasing transparency in multiple realms,
such as science, business, government, and politics.
This growing cultural shift toward transparency over
the past 50 years has been seen in such noteworthy
initiatives such as WikiLeaks or the Obama Admin-
istration’s Open Government Program. This trend is
also noted in health care, from the movement toward
acknowledging fault in medical errors, to multiple
public data sources on health care provider practices.
This paper addresses some of the recent trends in
federal, state, and private initiatives that seek to shed
light on health care provider practice in general, and
includes information on nurse practitioners (NPs)
more specifically. Policy and practice implications of
current transparency initiatives are highlighted.
THE PATIENT PROTECTION AND AFFORDABLE CARE
ACT: SUNSHINE PROVISIONS
In 2010, Congress passed the landmark Patient
Protection and Affordable Care Act. One less well-
known provision of the law, the Sunshine Act
(Section 6002) was included in order to increase
the transparency of financial relationships between
health care providers and the pharmaceutical and
urnal for Nurse Practitioners - JNP
medical devise industries.1 The Sunshine Act grew
out of an increasing concern regarding the financial
relationships that physicians have with industry.
Although some of these relationships are thought
to be beneficial and contribute to the development
of new drugs and devices, other relationships can
generate conflicts of interest in both research and
practice. Numerous studies over the past 20 years
have reported high levels of financial interaction
between physicians and the pharmaceutical

industry.2-5 Broadly, these studies demonstrate
that payments in the form of speakers fees, meals,
consulting, and sponsored continuing education
programs impact clinical decision-making and that
such interactions between clinicians and industry
can lead to biased prescribing practices and conflicts
of interest.6,7
The Sunshine Act requires that all pharmaceutical
and medical device manufacturers providing products
via Medicare, Medicaid, and the Children’s Health
Insurance Program disclose payments made to
hospitals and all licensed physicians (doctors of med-
icine, osteopathy, dentists, podiatrists, optometrists,
and chiropractors). These payments are reported
to the Center for Medicare and Medicaid Services
(CMS) and are available on the public website Open
Payments (www.cms.gov/OpenPayments/). The
Volume 12, Issue 3, March 2016
http://www.cms.gov/OpenPayments/
http://crossmark.crossref.org/dialog/?doi=10.1016/j.nurpra.2015
.09.017&domain=pdf
On Oct. 7, 2015 Senators Grassley (R-Iowa) and
Blumenthal (D- Connecticut) introduced Senate Bill S.
2153, an amendment that would require industry to
include information regarding payments made to
physician assistants, nurse practitioners, and other
advance practice nurses in transparency reports sub-

mitted to the Center for Medicare and Medicaid, Open
Payments website.
types of payments that are reportable include general
payments, such as speakers’ fees, honoraria, travel and
entertainment expenses, food, and education. Pay-
ments of < $10, unless over the course of a year
exceeding $100, are exempt. Investment interests
and research payments are also included.
It is important to note that other health care
professionals who have prescriptive authority, such as
NPs, physician assistants (PAs), psychologists, and
pharmacists (in designated states), are not included in
the statute. The exclusion of these professionals has
generated broad concern for several reasons. NPs
and other prescribers have been described as being
vulnerable or “soft targets” to industry’s promotional
activities, and flying “under the radar” of educational
initiatives that seek to mitigate conflicts of interests
between industry and prescribers.8,9 Also, the omission
of data on other prescribing clinicians may incentivize
manufacturers to shift financial relationships to these
other prescribers.10 Moreover, as transparency expands
around the financial transactions between physicians
and industry, other prescribers who are not included in
the law may become more vulnerable to the conflicts
of interest that have heretofore plagued physician/
industry relationships.11
Federal Data Surprises
Despite the fact that NPs, PAs, and other prescribers
were not included in the federal Sunshine statute,
many manufacturers, nonetheless, are reporting pay-
ments made to these prescribers. This information is

publically available on the CMS Open Payments
website. NPs and PAs are listed together in 1 category:
Physician Assistants & Advance Practice Nursing
Providers/Nurse Practitioners. Additional designations
are listed by specialty, namely Adult, Family, Acute,
Pediatric, Psych/Mental Health, Women’s Health, and
Neonatal. The initial data (August to December 2013)
were released in 2014, and the full data for 2014 were
released on June 30, 2015.
Importantly, the data disclose specific identifying
information, such as name, workplace address, and
specialty. The data also include the total dollar
amount that the individual has received; what the
payment covered, such as food and beverage, travel,
speaking fees, consulting, etc; and the drug or
www.npjournal.org
medical devices being promoted, along with the
name of the manufacturer. It is important to note
that, although this broad category does not differ-
entiate NPs from PAs, the information is readily
available on the internet with a simple Google search
of the clinician’s name.
Although the information provided in the Open
Payment website is very specific and detailed, it is not
comprehensive and does not include information
from all manufacturers. Notably, a number of larger
companies, such as Pfizer, Eli Lilly, and Boehringer
Ingelheim, are not included on the list of manufac-
turers that provided payments to NPs and PAs. It is
likely that they chose not to report NP and PA data
as it was not their legal responsibility to do so. For the
companies that did choose to submit payment in-
formation for NPs and PAs, the reasons for doing so
can only be postulated. It may be due in part to a

companies’ interest in total transparency of payments
made to prescribers, or may simply be a result of the
difficulties in teasing out provider designations. It is
important to note, however, that CMS designated
this provider type in their data because provider
designations were based on the federal government
taxonomy codes for health care professionals (CMS,
personal communication, July 9, 2015).
Embedded in these data were 1,711 reports of
payments made to NPs and PAs in 2013 and 1,618
reports of payments made in 2014. The total
amounts reported in the data were $82,843 for 2013
(5 months) and $75,567.59 for 2014. However, the
average amount paid to these providers was $47.14,
with the vast majority of payments categorized
under Food and Beverage. Also, there were errors
noted in the data because some of the covered re-
cipients, while being identified as NPs or PAs, were
actually physicians.
The Journal for Nurse Practitioners - JNP 167
http://www.npjournal.org
STATE-LEVEL TRANSPARENCY INITIATIVES
Currently, there are 9 states that have enacted
legislation that mandates the transparency of in-
teractions between health care providers (institution
or individual) and the pharmaceutical and medical
device industries. The laws, which vary by state,
typically include behavioral prohibitions (bans or
limits on gifts, meals, or entertainment) or disclosure
requirements (the nature, value, and purpose of
industry-sponsored payments or activities).12

Minnesota was the first state to enact “Sunshine”
legislation in 1993 with other states following suit
over the ensuing 2 decades.
Massachusetts enacted the Pharmaceutical and
Medical Device Manufacturer Code of Conduct
Law in 2010,13 which is widely considered to be one
of the most comprehensive laws of its kind in the US.14
This law requires that health care practitioners not only
disclose payments from industry but also banned certain
gifts and meals that are provided in non‒health care
settings.15 Although the Law was amended in 2012
to allow for meals in some non‒health care settings
(ie, restaurants), it still maintains comprehensive
disclosure requirements for practitioners who fall
outside the federally mandated Sunshine Act.16
Six of these states or jurisdictions (Vermont,
Minnesota, Massachusetts, West Virginia, Con-
necticut, and the District of Columbia) include
NPs in their definition of “covered recipients.” This
includes full bans for food (Vermont), a prohibition
on practitioner gifts (Minnesota) to other reportable
activities, such as the receipt of samples (Vermont),
attendance at industry-funded educational events,
and other payments for speaking and consultation.17
Moreover, 2 states recently expanded their disclosure
laws to include other advanced practice clinicians,
in part because these prescribers were not included
in the federal Sunshine Act reporting obligations.
Minnesota expanded their law in 2014 to include
NPs, PAs, and dental therapists (HF 2402).18
Connecticut recently passed legislation in 2014 aimed

to create reporting mechanisms of industry payments
that are made specifically to advanced practice
registered nurses. Also, this is the first such law in the
US that was directly tied to a state’s independent
scope of practice law for advanced practice registered
nurses (see Table).19
The Journal for Nurse Practitioners - JNP168
MEDICARE REIMBURSEMENT AND PRESCRIBING
DATA
Since the inception of Medicare 50 years ago,
CMS has concealed the claims records of providers
participating in Medicare. This secrecy was upheld as
a result of a permanent injunction in 1979 that was
won by the American Medical Association against
Medicare to prevent the release of physician payment
data. In 2013, this injunction was lifted by the US
District Court in Florida. As a result, in 2014, CMS
released the first public use files that identified pro-
vider payment claims.20
Moreover, as a part of the Obama Administra-
tion’s goals of “better care, smarter spending, and
healthier people,” CMS released Medicare Part D
data, identifying the providers and the drugs pre-
scribed. The purpose of the release of these data was
to provide transparency to consumers, researchers,
health systems, and other stakeholders to identify
how many prescription drugs are prescribed by
individual prescribers and how much these drugs
cost the health system.21 Although public, the data
are not easily manipulated and there are no data
tools, such as in Open Payments, available at
this time.
OTHER PUBLICALLY SEARCHABLE DATABASES
News outlets are taking notice and are starting to

utilize data that have previously been difficult to
access or was unavailable. Propublica, an indepen-
dent, not-for-profit organization that produces
in-depth investigative journalism in the public interest,
provides several data sources that contain NP data and
are searchable by the public. Based on their data tools,
they have published numerous articles that pertain to
health care, which have earned a number of promi-
nent journalism awards, including 2 Pulitzer Prizes
(2010 and 2011) and a Peabody Award (2013).
Two of their recent investigations, Dollars for Docs:
How Industry Money Reaches Physicians and Prescriber
Checkup: Inside the Government’s Drug Data, are
particularly applicable to prescribing practices of
health care providers. These investigations include
numerous stories in series format and are accompa-
nied by user-friendly data tools that allow the public
to search for health care providers by name if
included in the federal data.
Table. State-based Transparency Laws
Covered Recipient
Disclosure/
Reporting
Law Reportable Activities Gift/Food Ban
Federal (PPACA:

Sunshine Act)
� MDs, DOs, DPMs
� DDSs, DMDs
� Teaching hospitals
Yes � Consulting
fees
� Honoraria
� Speaking fees
� Food
� Travel
� Entertainment
� Role in CME
� Research
� Royalties
� Investment
No
VT � All from the
federal
Sunshine Act
� NPs, PAs,
� Pharmacists
� Employees of
prescribers
� Nonteaching
hospitals/clinics
� Health plans

� Pharmacies
� Universities
� Nonprofit
foundations
� Patient advocacy
associations
� Professional
associations
Yes � All from the
federal
Sunshine Act
� Samples
� OTC drugs and
devices
� Demo units
� Coupons
� Vouchers
� Co-pay cards
� Patient
starter kits
� Accredited
CME
� Patient

education
and disease
management
materials
Total ban on
food and
other gifts
MA � All from the
federal
Sunshine Act
� NPs, PAs
� Residents
� Pharmacists
� Employees of
prescribers
� Nonteaching
hospitals/clinics
� Nursing homes
Yes � All from the federal
Sunshine Act
� Accredited CME

� Anatomic models, charts
Yes (allows
modest out
of office
meals)
MN � All from the
federal
Sunshine Act
� NPs, PAs
� Dental therapists
� Residents
� Not pharmacists
Yes ($50
limit on
meals)
� All from the federal
Sunshine Act
Yes
WV � All from the
federal
Sunshine Act

� NPs, PAs
� Residents
� Not pharmacists
Yes � All from the federal
Sunshine Act
� All national and print drug
advertising
No
DC All licensed health
care providers
(eg, RNs, CDEs,
nutritionists,
radiology techs,
etc.)
� Teaching and
nonteaching
hospitals/clinics
� Universities
� Patient advocacy
organizations

Yes ($25
limit on
meals)
� All from the federal Sunshine Act
� Print and media drug advertising
within DC
Yes
CT APRNs only (APRNs who work
independently according to newly
expanded scope of practice statute)
Yes (no
minimum
reporting
amount)
� All from the federal Sunshine Act No
APRN ¼ advanced practice registered nurse; CDE ¼ certified
diabetes educator; CME ¼ continuing medical education; DDS
¼ doctor of dental surgery; DO ¼ doctor of
ophthalmology; DPM ¼ doctor of podiatric medicine; MD ¼
medical doctor; NP ¼ nurse practitioner; OTC ¼ over the
counter; PA ¼ physician’s assistant; PPACA ¼ Patient
Protection and Affordable Care Act; RN ¼ registered nurse.

Adapted from: (1) Gorlach I, Pham-Kanter G. Physician
Payment Sunshine Act: review of individual state reporting
requirements. 2013. http://www.policymed.com/2014/04/
physician-payments-sunshine-act-review-of-individual-state-
reporting-requirements.html/; and (2) Finan A. Shining a light
on Connecticut’s version of the Sunshine Act.
2015. Available at:
http://www.law360.com/articles/659984/shining-a-light-on-
conn-s-version-of-the-sunshine-act/.
The Dollars for Docs series is based on 2 sources of
data. Beginning in 2010, Propublica compiled data
based on payment reports that resulted from legal
www.npjournal.org
settlements with the federal government. These set-
tlements often were based on whistleblower lawsuits
that alleged improper marketing or kickbacks. As a
http://www.policymed.com/2014/04/physician-payments-
sunshine-act-review-of-individual-state-reporting-
requirements.html/
http://www.policymed.com/2014/04/physician-payments-
sunshine-act-review-of-individual-state-reporting-
requirements.html/
http://www.law360.com/articles/659984/shining-a-light-on-
conn-s-version-of-the-sunshine-act
part of these settlements, pharmaceutical companies
entered into corporate integrity agreements with the
Department of Health and Human Services, Office
of the Inspector General. A number of companies
had corporate integrity agreements that mandated the
reporting of payments made to health care providers.
It was these payment data that populated Propublica’s

first data tool and provided the basis for the first series
of articles in the Dollars for Docs series.22 This first data
tool, which covers payments made between 2009
and 2013, contains numerous references to NPs that
are searchable by profession, name, and state, and is
quite robust in terms of identifying clinicians who
received payments from industry (http://projects.
propublica.org/d4d-archive/).
The second source of data used in the Dollars for
Docs series is based on information compiled from the
CMS Open Payments program. Like the data from
the Open Payments program, the Dollars for Docs
searchable tool contains information on payments
made to physicians and hospitals, and includes in-
formation on NPs and PAs. However, unlike the
Figure 1. Propublica’s Prescriber Checkup: Example NP Pee
De-identified.) From: Prescriber Checkup. Available at: http
1144295544/.
Used with permission from Propublica.
federal website, Dollars for Docs does not allow a
search based on specialty, and therefore NP or PA
data can only be searched based on name. Although
the majority of payments made to NPs and PAs in
these data are for small amounts, usually for food,
there are numerous references to payments made to
NPs for consulting and speaking, which amount to
thousands of dollars.
Prescriber Checkup (http://projects.propublica.org/
checkup/) represents a more robust, readily accessible
data source on NP prescribing. This data tool utilizes
Medicare Part D data for 2013 (which was released in

September of 2014). As noted earlier, Medicare data
had heretofore not been available publically and were
only accessible for researchers at a significant cost.
Propublica petitioned CMS via the Freedom of In-
formation Act for the Medicare Part D data for 2012
and CMS later independently released the 2013 data
as public use files. These data clearly designate all
prescribers, such as physicians, NPs, PAs, dentists, etc,
which are generated from National Provider Identi-
fier numbers. Personal information, including
r Comparison. (Figures for this Article have been
://projects.propublica.org/checkup/providers/
http://projects.propublica.org/d4d-archive/
http://projects.propublica.org/d4d-archive/
http://projects.propublica.org/checkup/
http://projects.propublica.org/checkup/
http://projects.propublica.org/checkup/providers/1144295544/
Figure 2. Propublica’s Prescriber Checkup: Example Data by
Schedule II Drugs. (Figures for this Article have been
De-identified.) From: Prescriber Checkup. Available at:
http://projects.propublica.org/checkup/providers/
1144295544/.
Used with permission from Propublica.
provider name, state of licensure, and workplace
address, is displayed.
Propublica also highlights the drugs that each
provider prescribes based on the following domains:

Drugs That Present Special Risks, such as Schedule II
or Schedule III drugs; and Cost of Prescribing, which
includes data on brand name drugs, prescription price,
and prescriptions per patient. It compares each indi-
vidual prescriber to other prescribers in the state, based
on state averages for controlled substances, brand name
drugs, prescription price, and prescriptions per patient
(see Figure 1). Also, Propublica provides the ability
to filter the provider’s prescriptions based on the
following categories: antipsychotic drugs; risky drugs
for seniors (based on the Beers List); benzodiazepines;
prescribing rank in the country for specific drugs; and
the prescriber rank according to their peers in the state
and by individual drug (see Figure 2). Propublica limits
the data to represent information on 410,022 providers
who wrote > 50 prescriptions for at least 1 drug to a
Medicare Part D recipient; 34,530 prescribers were
categorized as NPs.
www.npjournal.org
NPs in the News
Propublica’s Prescriber Checkup has spawned several
stories in the national media that have particular
pertinence to NPs. One story, published in The
Hartford Courant, “Connecticut Nurse One of the
Highest Prescribers in the US,” highlighted Pro-
publica data that shed light on an NP from that state
who was identified as one of the nation’s highest
prescribers of opioids and other Schedule II drugs.23
She ultimately pled guilty to receiving kickbacks
from the drug company, Insys Therapeutics
(Chandler, Arizona), in exchange for prescribing
large amounts of their drug, Subsys (fentynl
sublingual spray).24 Another story, “Transparency
Program Obscures Pharma Payments to Nurses,
Physician Assistants,” by National Public Radio and

Propublica, highlighted the financial ties that this
same Connecticut NP had with Insys Therapeutics.
She was a paid speaker for the drug company and
gave more than 70 dinner lectures for about $1,000
per event. It was noted that the payments for these
talks were not reported to the federal Open Payments
database because NPs and PAs are not included in the
statute of the Affordable Care Act.25
IMPLICATIONS FOR POLICY AND PRACTICE
Recent transparency initiatives that were originally
directed toward physicians are now touching NPs.
NPs, who are playing an increasingly strategic role in
our nation’s health care system, should embrace these
changes as they can only lead to increased quality and
improved efficiency. The Sunshine laws (both federal
and state) are intended to shed light on the amount of
money spent on marketing drugs and devices and to
mitigate the conflicts of interest that can arise when
financial relationships exist between health care
providers and industry. The pharmaceutical industry
spent $27 billion on drug promotion in 2012;
$24 billion of that amount was spent on marketing
directly to clinicians. Moreover, in 2013, 9 of the
10 largest pharmaceutical companies spent more on
marketing than the research and development of new
drugs.26 These expenditures are principally designed
to influence prescribing practices and promote
products.4,27

A recent systematic review published in PLoS
Medicine reported that “non-physician” clinicians
perceived disparities between themselves and their
physician colleagues in the areas of access to practice
resources and the affordability of attendance at con-
ferences. The authors noted that this perceived
disparity caused the non-physician clinicians to be
more amenable to interactions with industry as a way
to advance their status in the health care system or to
attain similar privileges that have heretofore been
afforded to physicians.28
Importantly, many authors have noted that the
exclusion of advanced practice clinicians (NPs and
PAs) from federal Sunshine statutes may serve to
incentivize industry to increase promotional activities
directed to this important provider group, due in
part to decreased public scrutiny.11,28 Indeed,
pharmaceutical industry marketing to advanced
practice clinicians is poised to grow exponentially.
This shift of payments to nonreportable clinicians
may eventually be empirically detected by quantifying
payment decreases to physicians, especially in states
where NPs have broader scopes of practice.29 However,
it may be that the inclusion of advanced practice
clinicians into federal Sunshine statutes would more
effectively mitigate the growing shift of marketing to
this group of providers as well as address the disparities
that exist in federal policy. Also, because of the federal
omission of advanced practice clinicians, states may
step in to create or expand Sunshine laws to include
this provider group.30 Connecticut’s recent statutory
addition that links transparency laws to expanded scope
of practice for NPs may become a model for state

legislatures that are considering expanded scope
legislation.
The public release of Medicare Part D claims data
may have broader implications for NP practice.
Medicare data have been described as the “eighth
wonder of the world,” due to the scope and breadth
of information they contain. These data represent
remarkable potential for researchers to be able to
quantify both quality and cost metrics of NP pre-
scribing practices. However, as has been noted in the
Propublica series, it also creates a facile source for
journalists and other researchers, who are becoming
increasingly interested in NP practice, to closely
scrutinize our prescribing activity. This scrutiny may
become progressively compelling and provocative,
especially because recent transparency initiatives, such
as the federal Sunshine provisions, do not include
advanced practice clinicians.
It will behoove NPs to be apprised of the infor-
mation that is available publically concerning their
interactions with industry as well as their prescribing
patterns, based on Medicare Part D data. This in-
formation provides a comparative context; NPs
should know if their practice patterns differ signifi-
cantly from other providers in their community. If
erroneous information is disclosed, especially in the
case of the Open Payments data, any clinician has the
recourse to submit corrections. However, in general,
we should know our numbers, because everyone
else does.
CONCLUSION
The prescribing behaviors of NPs have largely
remained “under the radar” in terms of policy ini-

tiatives directed at increasing transparency with in-
dustry. Except in a handful of states, industry is not
required to report their interactions with NPs. One
implication of this is clear. Promotional activities by
industry will certainly shift focus to this growing
group of non-reportable clinicians. This may or may
not matter as Medicare Part D data are now publi-
cally searchable with metrics related to expensive
brand-name drugs—precisely the drugs that are
marketed extensively. The time may be approaching
that we will have to consider who influences our
prescribing decisions, and ask ourselves the question:
Who is really paying for that “free lunch”. or
dinner?
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