Journals
Nurse prescribing: mental health in older people
March 26, 2010 by admin
Non-medical prescribing in mental health services has tended to focus on supplementary prescribing. This article describes a pilot in which a successful shift was made to independent prescribing in community mental health care services for older people.
The scheme worked this way: the non-medical prescriber assessed the patient, discussed the current issues and agreed treatment options with the consultant psychiatrist responsible for that patient - and was then responsible for seeing the patient, discussing the treatment, issuing prescriptions, and reviewing the medication, with ongoing discussions with the consultant as needed. Three senior nurses and four consultant psychiatrists were involved. Trust formularies were adhered to throughout the pilot.
Interviews, documentary evidence and patient questionnaires were all used to build up a picture of how the project worked, with encouraging results. The nurse prescribers felt that their relationships with patients were enhanced and that this, along with their accessibility, contributed to a coherent and responsive service. The authors conclude that they recommend this model.
Oldknow H et al. Independent nurse prescribing for older people’s mental health. Nurse Prescribing 2010; 8(2): 66-69.
Pharmacy prescribing and contraception access
March 26, 2010 by admin
The author argues that it is unlikely that schemes to make oral hormonal contraception available through pharmacy prescribing will contribute to a reduction in teenage pregnancies, and highlights all the other issues, as well as access, that are part of this problem. For example, the pilot schemes are unlikely to include under-16s, and if compliance is poor encouraging more women to take oral contraceptives rather than use other methods could result in more pregnancies.
Hand H. Widening access to contraception: the impact of pharmacy prescribing. Nurse Prescribing 2010; 8(2): 58-65.
Nurse prescribing supports diabetes services
March 23, 2010 by admin
Nurse prescribing ’supports and enhances’ established diabetes services, according to the conclusion of this case study of nine English settings in which nurses prescribe for people with diabetes.
Semi-structured interviews with nurse prescribers and other team members (administrative staff, doctors and non-prescribing nurses) revealed that the specialist nurses tended to treat patients with poorly controlled diabetes whereas nurses in general practice usually cared for patients with better controlled diabetes and prescribed a wider range of medicines for diabetes and related co-morbidities. Scope of practice and levels of responsibility varied, with nurses in one general practice setting taking responsibility for the whole of diabetes care with little input from the GPs, whereas one diabetes specialist nurse had been prevented from prescribing for inpatients.
Nurse prescribing was seen as facilitating change rather than causing it, with the shift of diabetes services to the community perceived as the main driver for change. It did, however, provide the flexibility and impetus to consider different ways of working: nurses in general practice were introducing a single review process in which patients with diabetes and co-morbidities had all their conditions reviewed at the same time. Prescribing by nurses was seen as helping to provide a more streamlined, responsive service, with good teamworking being important, for example in sharing information about new medicines.
Carey N, Stenner K and Courtenay M. How nurse prescribing is being used in diabetes services: views of nurses and team members. J Nursing Healthcare Chronic Illness 2010; 2(1): 13-21.
Specialist mental health nurse prescribing: professionals’ views
March 11, 2010 by admin
Once again, education for other professionals about the training and role of non-medical prescribers has been identified as an issue, this time in establishing nurse prescribing in specialist mental health teams.
In this case study, which aimed to explore the views and experiences of professionals within one specialist mental health team, nine health professionals from different disciplines attended a focus group and two psychiatrists were interviewed separately.
In general, the views were positive and a range of benefits identified including improved care and more teamworking. One striking finding in the focus group was that there was very little knowledge about aspects of nurse prescribing: training, requirements, responsibilities and practicalities. So even in a team with a practising nurse prescriber, colleagues were uncertain about their role and responsibilities. In the psychiatrists’ interviews it became clear that they had no training or support for their supervisory role, and that they had some anxieties, which the authors link to the perception that they might be expected to supervise an inexperienced prescriber who might make errors that they would be responsible for.
Implementation of nurse prescribing in diabetes
March 11, 2010 by admin
‘Few current problems’ were reported by nurses prescribing for patients with diabetes and their colleagues in this case study, and initial implementation problems had been resolved. Diabetes services were ‘primed’ to assimilate nurse prescribing.
The interviews, with nurse prescribers, administrative staff, physicians and non-prescribing nurses, revealed some interesting findings. Discontinuing the extended formulary in 2006 had ‘a profound effect’: because these nurses could now prescribe insulin and oral hypoglycaemic agents independently, the preferred mode switched from supplementary to independent prescribing. This allowed nurses to make better use of their prescribing qualification. The authors suggest that supplementary prescribing may be less useful in the management of long-term conditions than was originally thought.
In this case study, prescribing was found to fit into pre-existing structures, which meant that it could be seen as improving efficiency without requiring major changes - this may have smoothed the road to implementation. Success also depends on organizational support, good relationships between professionals, and acceptance of the prescribing role.
Remaining barriers to prescribing for practice nurses
February 25, 2010 by admin
Many services in primary care are now led by practice nurses working at an advanced level but not prescribing, either independently or as supplementary prescribers. What are the barriers as perceived by these nurses? Age, salary, support and training all emerged as factors in this questionnaire survey of practise nurses in one English county where prescriber numbers are low.
The authors make recommendations to improve the situation, including some central funding for course fees and expenses for practice nurses, study time and mentoring systems, a funded post of professional lead for practice nurses in each Primary Care Trust (PCT), a clear career pathway for practice nursing, and realistic financial incentives for professional development.
Of the 251 practice nurses in the county, 151 responded to the survey, most of whom were mature and experienced. About one-third will be reaching retirement age within 15 years, so GPs and PCTs will need to provide incentives to recruit and retain practice nurses.
More than 90% were managing at least one chronic condition but of these only 17% held a prescribing qualification and nearly half did not hold or intend to study for the prescribing qualification. Similarly, 37% of those providing first contact care for minor illnesses did not hold or intend to study for the prescribing qualification. The intention to train was strongly related to age, as might be expected.
Other factors included lack of support, time factors, anxiety about prescribing or the course, and lack of interest or opposition by GPs. There was a widespread view that respondents would receive little or no financial reward for doing the course. The authors point out that few GPs have adopted Agenda for Change, which would ensure parity with NHS colleagues.
Kelly A, Neale J and Rollings R. Barriers to extended nurse prescribing among practice nurses. Community Practitioner 2010; 83(1): 21-24.
Non-medical prescribing for IBD: audit results
February 4, 2010 by admin
This article describes how an audit was taken of independent non-medical prescribing practice in one hospital in a large cohort of patients with inflammatory bowel disease (IBD), and the changes that were implemented as a result.
When the IBD nurse specialist began prescribing, it was agreed that prescribing practices would be regularly audited. The results showed that prescribing practice was safe and evidence-based, but that there were some variations in it. As a result, a list of recommendations for practice was developed, for example about whether enteric-coated prednisolone is needed, and the necessary changes implemented.
Greveson K. An audit of independent non-medical prescribing in inflammatory bowel disease. Gastrointestinal Nursing 2009; 7(10): 23-27.
Diabetes care enhanced by nurse prescribing
February 4, 2010 by admin
This case study of nurse prescribers caring for people with diabetes found that the care they provided was enhanced by prescribing and that their prescribing and communication skills integrated well.
The evidence and analysis from interviews, patient questionnaires and videotaped consultations highlighted their good communication skills - particularly empathy and listening. The consultations included clear exchanges of information about medicines management and self-care. These aspects of care are particularly important to people with diabetes. The process was also seen as more efficient by nurses, and the patients reported good access and short waiting times.
The nurse prescribers were less consistent about explaining the risks and benefits of treatments and their side effects, a concern which has been noted before, although it is always difficult to know what had been said in previous consultations. In addition, although prescribing by nurses was seen as conferring some safety benefits (for example, that doctors were not signing prescriptions for patients they had not seen), the nurses did not consistently explore the use of non-prescribed herbal or over-the-counter medicines.
Courtenay M, Stenner K and Carey N. An exploration of the practices of nurse prescribers who care for people with diabetes: a case study. J Nursing Healthcare Chronic Illness 2009; 1(4): 311-320.
CPD needs for nurses prescribing in diabetes
January 20, 2010 by admin
Although the provision of continuing professional development (CPD) opportunities for nurse prescribers who care for people with diabetes has improved, according to this survey, pharmacological knowledge is still the area identified as being of concern. This is something education providers may wish to consider when developing CPD programmes to meet the needs of nurses prescribing in diabetes.
The article considers the finding from 439 respondents, all prescribing medicines for patients with diabetes, who completed a questionnaire as part of a larger group randomly selected from the Nursing and Midwifery Council (NMC) database. Many (63%) worked in general practice and most (more than 80%) said they had accessed CPD to support their prescribing. The results suggest that there has been recent and considerable improvement in the provision of CPD for this group, although the authors point out that this may also reflect established CPD opportunities in diabetes management for health professionals.
CPD in pharmacology has often been identified as a concern (albeit mostly either in the early groups of independent prescribers or in prescribing by health visitors and district nurses) and it arose again here - though possibly for rather different reasons. A large proportion of those nurses saying they had CPD needs (often not the more senior nurses) said they were in pharmacology for diabetes (including insulin and oral hypoglycaemic agents). Given the high numbers working in general practice the authors suggest that this may reflect policy changes that mean nurses in general practice are becoming more involved in starting people on insulin or managing more complex cases. Another are identified was on prescribing policy, which is not surprising given the rapid pace of change recently.
Carey N and Courtenay M. An exploration of the continuing professional development needs of nurse independent prescribers and nurse supplementary prescribers who prescribe medicines for people with diabetes. J Clin Nursing 2010; 19: 208-216
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.
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