Journals
Professionalism and ethics
July 25, 2010 by admin
In this article, the author discusses what professionalism means in the context of advanced nursing practice, and discusses the nature of conscientious objection, for example in the area of reproductive medicine and abortion. As nursing practice extends, along with technological and medical advances, non-medical prescribers may find themselves faced with new ethical dilemmas.
Another issue is that of conflict of interest, particularly between professionals and any private interest whose income depends on the professionals’ approval or prescription of their product - so including but not limited to the pharmaceutical industry. The author says that non-medical prescribers need a better understanding of the Association of the British Pharmaceutical Industry (ABPI) Code of Practice, and that perhaps there should be active policing of the Code and publication of case details. The article also points out how many drug trials, and how much nursing and medical education, are funded by the pharmaceutical industry and the impact this has. There is accumulating evidence that does not support the industry’s stance that education is the true intent of its programmes, argues the author, who says that there is now a body of thought that policies and guidelines are needed in this area.
Nurse prescribing extends beyond the therapeutic alliance into areas of research, human rights, policy, promoting change, financial issues and ethics. The author concludes by urging the Nursing and Midwifery Council (NMC) to set the highest standards, provide robust guidance for practitioners and show that it is willing to stand up to private industry.
Young A. Professionalism and ethical issues in nurse prescribing. Nurse Prescribing 2010; 8(6): 284-289.
Practice nurses and prescribing
July 25, 2010 by admin
What is the experience of prescribing for practice nurses, how do they feel about it, and what has its impact been on their role? These were some of the issues explored in a small, qualitative study using semi-structured interviews with eight prescribing practice nurses. Their experiences were mainly positive, but some tensions with medical colleagues in particular remain.
Many or all of the nurses felt that there were benefits for patient care through prescribing, that there were misunderstandings among practice staff about their role, that it is both ‘imperative and intuitive’ to follow appropriate guidance, that their role had changed as a result of prescribing, and that they were unwilling to prescribe outside their competence or boundaries. Some felt that workload had increased. It emerged during the interviews that minor illness is increasingly being incorporated into the role of these nurses. Although some GPs welcomed the change and were supportive, others were less happy about it and lacked understanding about the nurse prescriber’s role and competency.
The authors make some recommendations: all staff working with prescribing nurses should get full explanations of the circumstances in which they can prescribe; after the initial mentoring period, doctors or experienced nurse prescribers should provide a further period of mentoring and supervision, to further mutual respect and understanding; and a continued learning or system of monitoring could be introduced to help nurse prescribers demonstrate their credibility - as nurses’ roles extend, something like the GP performance monitoring system may become more appropriate. Clearly, as the authors point out, this is a small study and further work is needed.
Daughtry J. and Hayter M. A qualitative study of practice nurses’ prescribing experiences. Practice Nursing 2010; 21(6): 310-314.
National approach pays off in Ireland
July 14, 2010 by admin
Two articles about the implementation of nurse and midwife prescribing in Ireland have highlighted the importance of a structured, national approach. One [1] describes the national processes used and argues that the “critical success factor” was “the introduction of a standardised approach applied in a systematic manner by each health service provider….”. Another [2] describes how one aspect of the national framework used to support the initiative, the national nurse and midwife prescribing minimum dataset, was developed - and how its reports can be used to examine the prescribing activity of nurse prescribers in Ireland.
[1] Adams E et al. Prescribing in Ireland: the National Implementation Framework. Nurse Prescribing 2010; 8(4): 182-188.
[2] Adams E et al. Nurse and midwife prescribing in Ireland: the Minimum Dataset. Nurse Prescribing 2010; 8(5): 234-241.
Patients ‘confident’ about nurse prescribing
June 25, 2010 by admin
In diabetes care, patients were confident about nurse prescribing and reported improved access to medicines and greater efficiency, in this interview-based study. The 41 patients with diabetes were under the care of a seven nurse prescribers - some general practice nurses and some diabetes specialist nurses.
Interestingly, the patients were able to demonstrate specific improvements in efficiency and access - for example, being able to get an appointment with a nurse at short notice. Nurses were seen as more flexible than doctors but doctors’ time was also perceived as more important! So, nurse prescribing had contributed to improving the service in ways which patients noticed and cared about.
Patients expected teamwork among health professionals, preferring to see doctors for conditions perceived to be more serious or undiagnosed, and expected nurses to have had the necessary training and experience, as well as specialist diabetes knowledge, if they were to prescribe. Confidence in their ability to prescribe was inspired by these attributes and also patients’ direct experience, nurses’ willingness to refer to doctors or others when unsure, good communication skills, and attention to detail.
Patients of the diabetes specialist nurses expected the nurse prescriber to prescribe new medication or equipment but only that related to diabetes. In contrast, some patients of the general practice nurses saw the role as monitoring and continuing to prescribe medication initiated by the doctor although others were happy for the nurse to prescribe medicines for co-morbidities - there was a varied range of views among these general practice patients.
The authors conclude that workforce planners need to include services provided by nurse prescribers alongside those of doctors.
Pharmacist prescribers’ skills going unused
June 19, 2010 by admin
The skills of pharmacist prescribers, particularly in primary care, are not being used to the full, according to the results of this study in north-east England which confirms previous anecdotal evidence. So, what are the barriers?
A major stumbling block is the absence of clear organisational strategies (something that will be familiar to some nurse prescribers). Some pharmacists have never used their prescribing qualification. Organisations need to develop prescribing roles that are underpinned by policies and procedures. Some individuals have worked hard to use their skills to improve patient care and it is clear that pharmacists can set up and run innovative services that focus on patients. New roles need, however, to be ‘embedded’ in an organisation to be sustainable. Lack of funding, insurance costs, and controlled drugs regulations were also seen as barriers.
In secondary care, pharmacist prescribing seemed to be better established, with almost 10% of hospital pharmacists being prescribers, although preliminary results suggest that the overall number of items prescribed is small. In the absence of a strategic plan for how pharmacist prescribing should develop, the existing working relationships between hospital pharmacists and medical colleagues make it easier for individual services to develop as a results of those relationships. The logistics - access to medical records and prescription pads - are also more straightforward. Support from colleagues, networking and continuing professional development were also seen as easier to develop in secondary care as there is more teamworking.
Pharmacist prescribing in primary care is tiny - accounting for less than 1% of all items prescribed in this part of England. The picture is varied regionally, however, with pharmacists in some areas prescribing more than in others.
Baqir W, Clemerson J and Smith J. Evaluating pharmacist prescribing across the north east of England. B J Clin Pharm 2010;2:147-149.
Training of pharmacists as supplementary prescribers
May 30, 2010 by admin
This study used focus groups, interviews and analysis of recorded critical incidents to look at how GPs and pharmacist supplementary prescribers see the different aspects of the supplementary prescriber training, and continuing experience, in the context of the challenge to professional territory presented by the role changes involved in the non-medical prescribing policy.
Although some of the GP partners in the practices concerned were vocal about their concerns surrounding non-medical prescribing, and often anxious about the issue of diagnosis and exactly what it involves, the designated medical practitioners (DMPs) in each case were supportive. The pharmacists, all of whom had previously established effective working relationships with the practices as they worked as prescribing advisors, were very enthusiastic about their period of learning in practice, and the skills of the DMPs. The academic component of the training was less valued, although they did acknowledge that the reflective learning skills they gained were useful later in their work-based learning. Interestingly, reciprocal learning was acknowledged by both the DMPs and the pharmacists, and it seems that the DMPs were seeing their pharmacist colleagues in a new light as a result and were developing new ways of working together. Learning on the job was a key component of continuing professional development.
Tann J et al. The great boundary crossing: perceptions on training pharmacists as supplementary prescribers in the UK. Health Education Journal 2010; 69: 183-191.
Mixing medicines - legal aspects
May 30, 2010 by admin
This article provides an account of the legal situation around independent nurse prescribing, unlicensed medicines, and mixing medicines (see here and here). Although it is the responsibility of the relevant health professional to decide if the person has needs that can only be met by an unlicensed medicine, the author believes it is likely that trusts and boards will seek to limit their use on cost grounds. At present, the situation about controlled drugs has not changed, so mixing products that would create an unlicensed controlled drug is not covered.
Have the legislative changes and recent guidance made any difference to your practice? Why not log into the members’ forum and share your experiences?
Griffith R and Tengnah C. Prescribing and administering unlicensed medicines. Br J Community Nursing 2010; 15(5): 232-235.
Why do nurses prescribe antibiotics for otitis media?
April 25, 2010 by admin
Why do nurse practitioners in primary care prescribe antibiotics for children with otitis media and what influences them to prescribe outside guideline recommendations? These were some of the issues explored in this interview-based study with eight nurse practitioners who were independent prescribers. Previous studies have suggested that nurse practitioners and physicians prescribe in a similar manner, but there has been little work on identifying and analysing the factors that lead them to prescribe antibiotics or how they think through their prescribing practice.
The evidence is that most cases of otitis media are viral and self-limiting and do not require antibiotics, with the option for a delayed prescription when the antibiotic indications are borderline or the parent needs reassurance. Most of the nurse practitioners described occasions when they would reject the guideline recommendations, and external influences were sometimes at play here (such as time of day, lack of family knowledge, location). The authors conclude that efforts to reduce antibiotic prescribing will need interventions that are workable in practice and focus on those situations where nursers override policy and research evidence.
Philp A and Winfield L. Why prescribe antibiotics for otitis media in children? Nurse Prescribing 2010; 8(1): 14-19.
Nurse prescribers resisting ‘mini-doctor’ role
April 25, 2010 by admin
Nurse prescribers were resisting becoming ‘mini-doctors’, striving instead to maintain a holistic, patient-centred nursing style while adopting prescribing, in this small, interview-based study of nurses who prescribe for people with diabetes and their colleagues.
The nurse prescribers wanted to retain the nursing focus - including holistic assessment, health promotion and patient-centred care - that they see as particularly important in the care of people with diabetes; doctors interviewed concurred that this style of consultation was important. Flexibility over consultation times is therefore vital and had been the subject of discussions in some settings. Interestingly, it is not the introduction of prescribing by nurses that threatens this model but the drive for greater service efficiency.
Perceived approaches to decision-making provided some interesting contrasts: nurses in general practice were seen as tending to make decisions within current guidance or protocols, referring to a doctor where necessary; diabetes specialist nurses (DSNs), however, reported that their roles involved the higher levels of decision-making skills traditionally associated with doctors - using clinical judgement to prescribe outside standard protocols. In general practice, nurses’ prescribing decisions were often monitored by doctors, perhaps because they were prescribing a wide range of medications including those for comorbidities. DSNs were highly specialised, prescribing from a narrow range of diabetes medications.
Stenner K, Carey N and Courtenay M. How nurse prescribing influences the role of nursing. Nurse Prescribing 2010; 8(1): 29-34.
Prescribing responsibilities and litigation
March 26, 2010 by admin
This article sets out the legal background to the development of nurse prescribing in its various forms and runs through the safeguards - such as acting within competence, record keeping and indemnity insurance - that can help reduce the possibility of litigation.
McHale JV. Nurse prescribing: does more responsibility mean more litigation? Br J Nursing 2010; 19(5): 315-317.
Categories
Recent Posts
- Professionalism and ethics
- Practice nurses and prescribing
- New CKS topics
- National approach pays off in Ireland
- CDs: Another question asked in Lords
- Patients ‘confident’ about nurse prescribing
- Push for non-medical prescribing in Wales
- Insulin safety guidance issued
- Prescribing book - July publication
- Pharmacist prescribers’ skills going unused
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