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CD legislation timetabled for December

December 19, 2009 by admin 

The changes to allow nurse and pharmacist independent prescribers to prescribe controlled drugs within their competence are now scheduled for this month, according to a list of secondary legislation published by the Home Office. So the New Year should bring this long awaited change!

Nurse prescribing in acute care

December 19, 2009 by admin 

Motivation and commitment on the part of nurse prescribers themselves helped make the introduction of nurse prescribing successful in one acute care trust, as described in this article. Clinical teams recognised that the development represented both progression for individual nurses, and for the teams to which they belonged, and colleagues saw the new roles as fitting into existing team structures and being of benefit.

Imperial College Healthcare NHS Trust (ICHT) has trained over a third of its clinical nurse specialists to become non-medical prescribers and will be training 30 more non-medical prescribers a year. How has it implemented this initiative and overcome the barriers such as lack of support or appropriate systems that can hinder successful implementation?

Using a ‘force field analysis’ with ‘driving’ and ‘restraining’ forces, the new prescribing policies included guidelines to maintain the driving forces and promote support, team work, good supervision, effective mentorship and access to information, education and training programmes. The prescribing practice of the 66 independent nurse prescribers trained so far relates directly to the development of new roles and services, for example in caseload management in renal services and round-the-clock prescribing. They are all responsible for evaluating their own practice and use peer audit and professional development activities including action learning sets, small groups who meet regularly to raise concerns, discuss solutions and identify actions (both doing and learning).

An evaluation of the nurse prescribing roles identified a shared vision of, and commitment to, working differently among staff as a key factor in success. This allowed nurse prescribers to overcome some of the barriers to prescribing.

Jones K. Developing a prescribing role for acute care nurses. Nursing Management 2009; 16(7): 24-28.

Quantities, frequencies and timing important in prescription writing

December 19, 2009 by admin 

Information about the number of days a medicine should be taken for, total quantities of medicines and clear and accurate instructions about their frequencies and timing, were often omitted by nurse prescribers writing prescriptions for people with diabetes in general practice, in this small study. In general, the nurse prescribers did comply with good practice in their prescription writing, and used computer-based repeat prescribing systems to generate prescriptions for the management of diabetes and its common complications.

The prescriptions were issued on the appropriate form, written in ink legibly, using correct terminology, generic prescribing and with accurate/appropriate product, dose and preparation.

The authors point out that most of the prescriptions were for ongoing medications, which may help to explain the omissions, and also that nurses may be prescribing according to local custom and practice. However, nurse prescribers should not make assumptions about what patients remember and understand from the information they have been given, and such omissions may contribute to non-adherence: it is therefore important that every effort is made to ensure that all prescriptions include these vital pieces of information.

Prescriptions issued for 19 patients including 47 medicines were examined from four case study sites.

Carey N, Stenner K and Courtenay M. Prescription writing for diabetes: compliance with good practice. Nurse Prescribing 2009; 7(10): 464-468.

Gaps identified in nurse prescribing research

December 19, 2009 by admin 

There is ‘a stark absence’ of evaluations of nurse prescribing from professionals working in a general hospital setting, according to some of the conclusions of this two-part literature review of research on nurse prescribing [1,2]. More research is needed into the views of doctors and other healthcare professionals in acute hospitals, say the authors, commenting that the gap is surprising as many nurses are working as clinical nurse specialists or advanced nurse practitioners in hospitals, presumably in close collaboration with medical colleagues.

Patients seem to view nurse prescribing favourably, and the benefits of nurse prescribing include convenience for patients, improved time management, cost-effectiveness and improved concordance. The authors comment that some randomised controlled trials comparing outcomes from doctors’ and nurses’ prescribing would be useful to provide empirical evidence about the impact of nurse prescribing. Research that compares their decision-making processes is also warranted.

1. Creedon R et al. An evaluation of nurse prescribing. Part 1: a literature review. Br J Nursing 2009; 18(21): 1322-1327.

2. O’Connell E et al. An evaluation of nurse prescribing. Part 2: a literature review. Br J Nursing 2009; 18(22): 1398-1402.

Prescribing errors: moving on from indifference and denial

December 19, 2009 by admin 

After years of indifference and denial about standards of prescribing, a corner has now been turned, according to the British Pharmacological Society (BPS). It says most professionals now agree that standards of prescribing must be improved and sets out plans to do so.

Commenting on the recent report from the GMC, the BPS asks why, when four out of five of its recommendations centred on education, this was not given greater emphasis?

The BPS solutions are:

• Improving education: a national eLearning project with the Department of Health and medical schools; more opportunities for prescribing practice in training; promoting return of pharmacological and other sciences into higher education.
• Setting improved standards and assessing them: medical student prescribing curriculum already agreed and implemented; working now on a national prescribing assessment tool for final-year medical students.
• Providing professional guidance: launched the BPS ‘Principles of Good Prescribing’.
• Fostering collaboration.
• Improving the system: the introduction of a national prescription sheet for use throughout all hospitals; discussion about electronic prescribing, improved decision support and supervisory structures in first years of training.

The introduction of a prescribing assessment would aim to show that agreed standards of competence have been met before graduation.

Taking stock of attitudes

December 13, 2009 by admin 

This feature article looks at how, in the face of opposition from the medical profession, non-medical prescribing has been introduced in stages. The predicted problems and disasters have not materialised: one, and only one, case of inappropriate prescribing has come before the Nursing and Midwifery Council’s (NMC’s) fitness to practice panel and Molly Courtenay points out that there is no evidence that nurses work outside their competence or make clinically inappropriate decisions. Her work has shown that doctors now seem to be happy about the nurses that they work with and know prescribing, but are more worried about nurse prescribing in general - and the possibility of ‘loose cannons’.

Bill Beeby, who chairs the prescribing subcommittee of the BMA’s General Practitioners Committee, is quoted as saying that all prescribers have to work within their knowledge and competencies and as long as nurse prescribers do that, then there are no issues.

Hawkes N. Handing over the prescription pad. BMJ 2009; 339:b4835.

Nurse prescribing: views of children’s nurses

December 13, 2009 by admin 

What do children’s nurses working in a specialist children’s hospital as nurse prescribers think about the prescribing role and how it has been adopted in practice? This interesting study concluded that nurse prescribing had a ‘domino effect’, with multiple effects across different aspects of care: the resulting safety improvements led to improvements in the speed and efficiency of the service, and allowed episodes of care to be completed by nurses, enhancing their relationships with patients. The outcome of all this was seen as better care for patients and more job satisfaction for nurses.

The safety aspect is particularly important as so many drugs are not licensed for children, and participants here believed that their expertise was also allowing them to pick up and correct prescribing errors. In contrast to the situation found elsewhere, however, these nurses had not found that nurse prescribing had an impact on the development of their roles or their knowledge base, perhaps because of the highly specialist nature of these services: nurse prescribing was supporting existing structures. There were, however, issues with workforce planning and resources which were seen as limiting the impact of nurse prescribing.

Carey N, Stenner K and Courtenay M. Adopting the prescribing role in practice: exploring nurses’ views in a specialist children’s hospital. Paediatric Nursing 2009: 21(9): 25-29.

New post for ANP committee member

December 13, 2009 by admin 

Matt Griffiths has just been appointed Visiting Professor of Prescribing and Medicines Management at the University of the West of England, a position which he says will allow him to continue the work he has been doing at the University of Northampton in bridging practice, policy and education.

Hospital prescribing errors nearly 10%

December 4, 2009 by admin 

There was an error in 8.9% of medication orders written in 19 acute trusts, according to the results of a study commissioned by the General Medical Council (GMC).  Almost all errors were spotted and corrected by others before they could affect patients, all grades of doctors made prescribing errors, the drugs most often involved were analgesics, antibacterials, bronchodilators and antianginals, and admission was the most common time for errors to be made. Foundation year one doctors actually had a slightly lower error rate (8.4%) than doctors overall.

Among its recommendations, the GMC proposes that a standard prescribing chart should be introduced throughout the NHS. The Medical Schools Council has supported this suggestion: its Chair, Professor Tony Weetman, said that “…..it would be a simple additional measure to improve the consistency of the teaching of prescribing skills by Medical Schools”.

The British Pharmacological Society (BPS), however, is less impressed:  ”the GMC appears to be maintaining the position that training is not a core issue to be tackled”. Professor Simon Maxwell, Chair of the BPS Prescribing Committee said, “Like everyone else, I am extremely concerned by this error rate but I am dismayed at the suggestion that improved education and training is not a central part of the solution”. He believes that a national form would only be one part of the solution to “a much more profound problem”.

The report’s recommendations include targets on: clinical working environments including a standard national form; undergraduate medical education programmes; Foundation year 1 education; other parts of the medical education continuum; and interprofessional education.

The report also includes some systematic reviews, in which a slightly lower error rate was found (median 7%) and in which errors were most common with antimicrobials. Incorrect dosage was the most common type of error and errors were more common in adults than children.

The report also says that doctors relied heavily on pharmacists and nurses to identify and correct errors and that a ’safety culture’ was ‘conspicuous by its absence’ from respondents’ discussions of their prescribing errors, the reported culture of their working environments, and the reported actions of other doctors.

Safe prescribing - ANP conference

December 4, 2009 by admin 

How can we work together to ensure that we maintain competency, access continuing professional development (CPD) and make sure patients get good care, in what is likely to be an increasingly difficult financial situation? asked Barbara Stuttle, ANP Chair, at the end of the ANP’s lively regional conference on ‘Ensuring Safe Prescribing Practice’, held in London on 26 November.

She urged her audience to start preparing to persuade managers that CPD is a right, not a luxury, as budgets tighten: CPD is essential to ensure continuing safe practice. Several nurse prescribers in the audience had funded their attendance and taken annual leave to attend. She also stressed the importance of making notes, recording incidents and - sometimes - challenging colleagues and changing practice.

The conference was chaired by Baroness Cumberlege, Patron of the ANP, who highlighted the tremendous progress made in the last 20 years, from a situation in which no nurses prescribed and queues formed outside doctors’ doors for them to sign prescriptions for unseen patients. The BMA’s fears that opening the formulary was dangerous have proved unfounded and soon, it is hoped, controlled drugs will be available too (see here).

Baroness Cumberlege stressed the importance of trust, a theme that cropped up throughout the day, and looked to the day when multiprofessional education becomes the norm.

Trust and confidence take years to build up but can be destroyed in an instant, pointed out Mark Gagan (senior lecturer, Bournemouth University) in his talk on legal developments in nurse independent prescribing. Following a series of scandals, the professions now need to restore public trust, and nurse prescribers must be able to justify what they do, both to build and maintain trust and confidence and for legal reasons. The work of the Nursing and Midwifery Council (NMC), Health Professions Council and the Council for Healthcare Regulatory Excellence highlights the increasing importance of regulation. Accountability is key: to the patient, criminal law, civil law and employer and, some say, to oneself.

For negligence claims, the claimant must prove that: a duty of care existed, the defendant breached the duty of care and was careless, and that carelessness caused harm to the claimant. Mark highlighted the importance of:

• Not giving casual advice to friends and neighbours.
• Checking adequate cover for damages is in place especially for those nurse prescribers working in GP surgeries or independently.
• Good record-keeping.
• Evidence-based practice (actions must have sound logical basis).

Turning to recent legislative developments, Mark examined the workings of the Mental Capacity Act and how competence is defined, the use of advanced directives, lasting power of attorney, and the current situation about mixing medicines and controlled drugs (see here and here).

A rich picture of the impact of the impact of nurse prescribing on service delivery is emerging, said Molly Courtenay (professor of clinical practice: prescribing and medicines management, University of Surrey), from her research in different therapy areas since 2004. Molly and her colleagues have looked at pain, dermatology, children and diabetes care, and have used a variety of methods to try to establish how the rollout of nurse prescribing is working in practice in different areas.

The data have provided evidence about how nurse prescribing is working from the following standpoints: efficiency and access; quality of care; safety; the impact on the team and changing models of care; and the support needed.

Less time being spent in waiting for doctors’ signatures, increased capacity partly through better use of skills in teams (for example in diabetes where nurses, nurse practitioners and doctors are seeing different groups of patients) and partly through enabling nurse-led services (for example, in dermatology), and improved access to medicines, have all boosted efficiency and access. The impact on the quality of care has also been positive, as nurse prescribers can complete episodes of care, and provide continuity of care and a holistic assessment: adherence to medicines and better prescribing decisions may both result from these changes.

Safety concerns have been much discussed since nurse prescribing was introduced but the evidence here, too, is reassuring: nurses are picking up errors, are prescribing safely, and have a tendency to stick to guidance, leaving more complex cases where this may not be appropriate to medical colleagues.

Professional roles have shifted, with doctors no longer signing prescriptions for patients they have not seen, and having time to concentrate on the more complicated cases. For diabetes specialist nurses, the prescribing qualification is becoming essential for career progression but in other areas, non-nurse prescribers are happy not to prescribe. In an interesting development, medical students from Cambridge University are attending a non-medical prescribing programme.

Support, as ever, is necessary but is still lacking in some areas. As well as CPD, supervision, and peer support, organizations need to make sure that policies and clinical governance are in place as non-medical prescribers come through the prescribing programme and that workforce planning considers the use of their skills. There is some evidence that pharmacist prescribers are not prescribing once they have qualified as their role, and the services they could deliver, have not been defined in advance.

Accountability, the evidence base, and good record-keeping were again highlighted by Fiona Culley (professional advisor, NMC), as she talked about developments in nurse prescribing from the perspective of the NMC. There is no room for “confusion and creativity” in prescribing and complacency and fear need to be balanced. Prescribers should review their prescribing practice in the light of the Code of Conduct and consider the various standards taken together. Interestingly, although prescribers now form nearly 10% of the register, and the NMC has 6-8 fitness to practice hearings a day, nurse prescribing has not been an issue.

Next year, nurse prescribers should look out for several developments on the NMC website: the next stage of consultation on pre-registration education; revised standards of proficiency for nurse and midwife prescribers; and progress on revalidation.

What is polypharmacy, how much of a problem is it for older people and how should it be tackled, were among the important questions addressed by Lelly Oboh (consultant pharmacist for older people, Lambeth PCT) in a fascinating talk that set out clearly exactly how older people in particular end up taking so many medicines, and the consequences it can have for them.

Polypharmacy can be defined as being on many drugs at the same time (usually four or five) but can also be seen as people being on any medicines they should not be on. To put the issue in context, 15% of over-75s in the community take five or more medicines, and nursing home residents take an average of six to eight and sometimes up to 20 medicines. In some cases, these may all be needed and valid but polypharmacy does have all sorts of negative consequences including more and longer hospital stays and poorer quality of life. Regular, thorough, medication reviews, good communication and record-keeping, alongside a wealth of other strategies, were set out by Lelly as ways of reducing polypharmacy.

There are lots of reasons why polypharmacy arises, particularly in older people, including multiple clinicians prescribing for the same patient, drugs becoming more available without prescription, multiple pathologies, and the impact of targets. It can be important to resist the temptation to prescribe and sometimes it is necessary to make difficult decisions about risks and benefits (which, again, should be carefully documented). Prescribers should think holistically, balancing efficacy of treatment with quality of life.

Older people have increased sensitivity to some drugs and can have impaired pharmacokinetics so, for example, the effects of sedatives can last longer, causing drowsiness and making falls more likely. For these and other reasons, they are often at increased risk from the effects of polypharmacy.

Medication errors are everyone’s concern, said Matt Griffiths (senior nurse, medicines management, University Hospitals of Leicester, and visiting professor, prescribing and medicines management, University of Northampton) in his session on medication errors and safety. He discussed the ‘Safety in Doses’ reports (one covering 2005 and half of 2006 and one covering all of 2007) from the National Patient Safety Agency, which make sobering (and worthwhile) reading but do contain some good news. Reporting of medication incidents has increased, and after earlier guidance on the safe use of potassium chloride injection and oral methotrexate, the report covering 2007 contained no incidents of death or serious harm involving these medicines.

The earlier report highlighted the fact that two groups of patients are associated with medication errors. One is people with allergies receiving a medicine to which they are known to be allergic (these accounted for only 3.2% of all hospital incidents but one-third of these caused harm). The other is children - children up to four years were involved in 10.1% of incidents where age was stated.

Matt looked at the different types of medication incidents - using examples that provoked gasps from the audience - and then at the key actions for improving medication safety. For example, one action is minimising dosing errors - but how is this actually done? Yes, use information, training and tools, direct efforts at high-risk patients (such as children) and high-risk drugs; but what about double checking - is it really independent or do we tend to assume that someone senior is better at the maths? What if it is simply impractical to double check every time because the regimen is so involved? Another action is ensuring medicines are not omitted and Matt explained how his Trust has introduced a system for patients self-medicating while waiting on admission, if the admission is nothing to do with medication and the patients are capable.

The tremendous progress made in nurse prescribing as well as the importance of good record-keeping, communication, evidence-based practice, and updating, were highlighted again and again during the day, which concluded with a choice of workshops on CPD using disease-specific case studies and decision-making processes. Look out on the website for news of the 2010 events - and come and see for yourself. Lowri Daniels

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