Nurse prescribers: what do dermatology patients think?
July 30, 2009 by admin
Dermatology patients were found to be very satisfied with the care they were given by nurse independent prescribers and nurse supplementary prescribers, in this study in which 165 (82%) patients treated by nurse prescribers from different convenience samples returned questionnaires.
The questionnaires asked patients about access and waiting times, continuity of care, communication during the consultation, outcomes of the consultation and satisfaction with the care received.
Continuity of care was seen as good and rated highly, suggesting that relationship continuity is an important aspect of the nurse-patient relationship: in particular, patients of the specialist nurses rated continuity highly - these patients are more likely to have long-term conditions.
All aspects of communication during the consultation were rated highly by patients, with slightly lower ratings being given to the amount of information patients received about their medicines. Patients of specialist nurses rated this aspect higher than those of GP nurses.
Overall, the authors conclude that the relationship nurse prescribers have with their dermatology patients and the length of the consultations are important features in this type of consultation. More research is needed on the information needs of dermatology patients, and on the effect of the nurse prescriber/patient relationship on medicines concordance and clinical outcomes.
Courtenay M, Carey N and Stenner K. Dermatology patients’ views on nurse prescribers. Dermatological Nursing 2009; 8(2): 38-44.
What barriers to nurse prescribing remain?
July 30, 2009 by admin
It is clear that despite the rapid growth in nurse prescribing, some obstacles remain, particularly in certain clinical areas. Two recent articles discuss some of these issues.
In one [1], the author traces the recent development of nurse prescribing and how it is now being implemented and argues that although it is now mostly supported by doctors, and there has been much progress, some barriers remain.
As predicted, the proportion of nurses qualified to prescribe independently who use supplementary prescribing has fallen since the formulary was opened up. According to Professor Molly Courtenay, that figure is now 20%, down from 40% in 2006, and she points out that some nurses prefer to use supplementary prescribing, to help build confidence and skills, or because their patients have complex conditions.
Some trusts are, however, requiring nurses to practice as supplementary prescribers for a period after qualifying, for a variety of reasons. These policies have their critics and can be seen as frustrating obstacles. Other restrictions include a lack of training and support once nurse prescribers have finished the course, as highlighted by recent research.
Another article [2] discusses nurse prescribing in mental health in Scotland, which has been slow to take off, and shows that evidence about what the barriers are is lacking, concluding that there is an urgent need for research in this area.
[1] Lomas C. Nurse prescribing: The next steps. Nursing Times 2009; 14 July.
[2] Ross J. Researching the barriers to mental health nurse prescribing. Nurse Prescribing 2009; 7(6): 249-253.
Updates on the management of skin conditions
July 30, 2009 by admin
Several articles have discussed the management of various skin conditions recently.
In one [1], the author discusses the management and treatment of people with psoriasis, describing the anatomy of the skin, the causes of psoriasis, and highlights how skin disease can have negative impacts on people’s lives, with social and financial implications.
The topical therapies available include: emollient, coal tar ointment, dithranol, vitamin D analogues, phototherapy, methotrexate, retinoids, and topical steroids. The topical treatment should be chosen according to the individual’s needs, and psychological therapy considered on the same basis. Preventative measures may include avoiding environmental factors such as smoking, sun or stress and also avoiding irritating cosmetics or soaps and scratching.
Another article [2] examines the effects of atopic eczema on children’s quality of life and the management options available. The author suggests that this condition is not always taken seriously by healthcare professionals: the condition can be distressing, complicated, frustrating and time-consuming to treat, and can affect the whole family.
A defective skin barrier is now thought to be a significant issue for atopic skin: when irritants and allergens penetrate the barrier, they can lead to eczematous lesions or worsening of symptoms. An interaction between environmental and genetic factors is thought to be involved.
The various treatment options are all discussed, together with the key role nurses play in education, empowering parents and children with clear and consistent advice. Infected eczema is also discussed, as it is here [3].
Pruritus in older people is discussed here [4], with the author stressing its impact and how common it is. It is important to investigate the cause of pruritus in older people: dry skin (xerosis) is the most common, but there are a range of others. Emollient therapy is key for any pruritus associated with dry skin and some practical techniques are explained, along with other management methods.
[1] Peate I. Management and treatment of the person with psoriasis. Nurse Prescribing 2009; 7(5): 198-203.
[2] Carr JD. Evidence-based management of childhood atopic eczema. Br J Nursing 2009; 18(10): 603-610.
[3] Watkins J. Infected eczema. Practice Nursing 2009; 20(6): 295.
[4] Wheeler T. Managing pruritus in the older person.
Br J Comm Nursing 2009; 14(6): 238-244.
Independent Nurse: Practical Prescribing
July 18, 2009 by admin
I am aware of the restrictions concerning controlled drugs (CD). However, is Diazepam a CD? Â I am involved in the care of patients with short-term anxiety who would benefit from this medicine. However, the trust in which I work restricts the prescription of Diazepam by Nurse Independent Prescribers (NIPs) to palliative care and alcohol withdrawal.
To read the reponse to this question, click here.
Planned changes good news for professionals and patients
July 11, 2009 by admin
The announcement this week by the MHRA about mixing medicines is good news for the professionals involved and for patients, and follows months of uncertainty about the legal situation around what has become common clinical practice in many areas, not just palliative care.
The planned changes to the law, due by the end of the year, will mean that:
- Doctors and dentists - who can already mix medicines themselves - will be able to direct others to mix (other than a pharmacist under existing legislative provisions, or by a person holding a manufacturer’s licence).
- Non-medical prescribers will also be able to mix medicines themselves - or direct others to mix, as above.
- The changes will apply to “all clinical areas where the mixing of medicines is accepted practice”.
- Nurse and pharmacist independent prescribers will be able to prescribe unlicensed medicines for their patients, on the same basis as doctors and supplementary prescribers.
The MHRA also says that its previous advice - that it will “not consider taking enforcement action against those prescribing and administering mixtures of licensed medicines in palliative care unless it would be in the public interest to do so”, with each case being considered individually - is now extended to cover other areas of clinical practice, to reflect the legal changes planned.
The ANP has said that there are many other areas of clinical practice where mixing medicines occurs and supported this approach (see here).
One example, says Matt Griffiths of the ANP and the Senior Nurse for Medicines Management at The University Hospitals of Leicester NHS Trust, is the mixing of nebuliser solutions: guidelines for asthma recommend mixing salbutamol with ipratropium bromide in some circumstances.
He added that, “This is great news for non-medical prescribers: they can now follow best practice and provide excellent care, without confusion over what is legal and what is not.” David Pruce, Director of Policy at the Royal Pharmaceutical Society of
Great Britain, said “We are pleased that ministers have accepted the recommendation of the Commission on Human Medicines. This will legalise the established clinical practice of mixing medicines in clinical areas and will allow nurse and pharmacist independent prescribers to prescribe unlicensed medicines. We believe that this settles a long standing anomaly that was never intended when nurse and pharmacist independent prescribing was introduced.”
Members of the ANP can share their views on this development in the community login section or see here for membership information.
Agreements and schedules help learning in practice
July 11, 2009 by admin
The learning experience of non-medical prescribing (NMP) students during their learning in practice period was significantly improved if they drew up a learning agreement and time schedule at the start with their designated medical practitioner (DMP), according to the results of this survey of 57 NMP students.
Learning agreements and time schedules were very important in ensuring that the students’ learning needs were met, despite time constraints and workload in practice settings. Spending more than 30 per cent of the practice hours under direct DMP supervision was significantly associated with student satisfaction and this was more common where a time schedule was in place. Formative assessment, resulting in greater student satisfaction, was also more likely if a prior learning agreement had been done.
The students identified barriers to learning, including: time and workload constraints, organizational issues and peer support. One recommendation that emerged was having a qualified, practising, non-medical prescriber acting as co-mentor. Other suggestions included providing incentives to doctors, giving them more information about NMP to encourage them to take up the DMP role, and that sponsoring organizations should have systems to support supervised periods of learning in practice.
Ahuja J. Evaluating the learning experience of non medical prescribing students with their designated medical practitioners in their period of learning in practice: Results of a survey. Nurse Educ. Today 2009; published online.
Pharmacist prescribing: a threat to medical dominance?
July 11, 2009 by admin
Has non-medical prescribing presented a threat to the professional dominance of medicine? So far, it seems not, according to the conclusions of this article describing interviews with 23 pharmacist supplementary prescribers, conducted early on during the implementation of supplementary prescribing for this group.
There was an interesting range of views over whether prescription writing itself is important to a sense of professional self-worth and the status associated with prescribing, or whether the decision-making processes that precede prescription writing are what are important. Some prescribing pharmacists appeared uncomfortable with the prescribing autonomy offered by supplementary prescribing.
There was also a range of views on which activities constitute prescribing, both in hospitals and in the community, for example dose adjustment. Prescribing can be seen as “a complex series of processes with distinct tasks and decision points” and pharmacists were involved in some of these activities under the former legislative regime: this has helped make the changes in the workplace acceptable. The emphasis on competence limits and safe practice, and on a team approach to managing patients, has also helped with legitimacy.
Medicine has, however, developed what the authors describe as an ‘overseer’ role over the prescribing process, controls the knowledge base for prescribing practice, and has retained its high status: it would seem debatable whether new prescribers have threatened medicine’s professional dominance.
Weiss MC and Sutton J. The changing nature of prescribing: pharmacists as prescribers and challenges to medical dominance. Sociology of Health & Illness 2009; 31(3): 406-421.
Non-medical prescribers will be able to mix medicines
July 8, 2009 by admin
Non-medical prescribers will be able to mix medicines legally - and direct others to do so - by the end of the year, under planned changes to the law announced yesterday by the MHRA. This will apply to any clinical area where mixing medicines is accepted practice. Nurse and pharmacist independent prescribers will also be able to prescribe unlicensed medicines for their patients.
The mixing of medicines has been a matter of huge concern for non-medical prescribers, and the ANP and other organisations have consistently lobbied for legislative changes to clarify the situation.
We will be covering this in more detail in the next few days but in the meantime, Matt Griffiths of the ANP, said “This is great news for non-medical prescribers: they can now follow best practice and provide excellent care, without confusion over what is legal and what is not.”
For the MHRA’s revised statement on medical and non-medical prescribing and mixing medicines in clinical practice click here.
News on PGDs
July 6, 2009 by admin
Can medicines be supplied under patient group directions (PGDs) when the patient is absent? Yes, in exceptional circumstances, says the answer to a new frequently asked question on the PGD website here.
The legal framework and associated guidance does not say that the patient must be present, so they do not have to be, but the requirements for PGDs mean that an adequate assessment is needed. Only when the circumstances are exceptional, and the use of a PGD in the absence of the patient unavoidable, should this be done, and assessment could then include a telephone conversation with the patient or a discussion with a close relative.
A recent editorial in Practice Nursing (volume 20, issue 6, p267) highlights the inconsistent and complex system for developing PGDs for general practices, with many Primary Care Trusts (PCTs) no longer willing to undertake this role. The author argues that a simpler system is needed: the RCN has asked for PGDs to be addressed in the review of medicines legislation but what should practice nurses do in the meantime? As non-medical prescribing leads in Strategic Health Authorities (SHAs) have apparently been made aware of the situation, practice nurses could contact their non-medical prescribing lead if they are having trouble getting PGDs authorised.
Non-medical prescribing: database of examples
July 6, 2009 by admin
The National Prescribing Centre (NPC) has launched a database of examples of non-medical prescribing implementation submitted to the NPC for sharing with the wider NHS. To submit an example, or read about other people’s experience, see here.
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