Journals
Non-medical prescribing in secondary care: more is needed
November 10, 2010 by admin
“When are the other night sisters going to do their prescribing course?” was the question asked of this orthopaedic night sister with a non-medical prescribing qualification working in a centre for elective orthopaedic surgery, by nursing colleagues who felt they were able to provide better care for their patients as a result of her prescribing. This interesting article describes an audit of the author’s prescribing practice and some of her experiences as a prescriber.
The plan for this prescriber had been that she would start by prescribing for patients on the close observation unit within the centre and then after three months to start prescribing for the rest of the centre, but in fact her skills were needed sooner than that by other wards.
An audit was conducted after four months using her prescribing diary, a list of drugs she was allowed to prescribe, annotated to indicate the number of times they were prescribed, and the Trust audit tool. This showed that her prescribing was readable, clear, correct and in line with local policy and guidelines. She was prescribing a mean of 5.4 times a night, with the most common items being analgesia and intravenous fluid The author comments that one issue was that she sometimes had to prescribe and administer medicines to a patient, so would ask another trained nurse to check and co-sign the prescription before administration. She points out also that it is appropriate not to prescribe in situations where the prescriber does not feel confident (an example was requests for night sedation from patients who had already had large amounts of morphine).
It is still unusual to find nurses prescribing in wards, although specialist nurses and nurse consultants are prescribing in hospitals: the author explains the rationale and benefits for introducing nurse prescribing in her particular setting, concluding that more non-medical prescribers are needed in secondary care.
Crew S. Non-medical prescribing in secondary care: an audit. Nurse Prescribing 2010; 8(10): 498-502.
Where has non-medical prescribing got to?
October 17, 2010 by admin
Non-medical prescribing needs to be fully and effectively integrated into service delivery and workforce planning if it is to be rolled out into new practice areas and its full benefits realised, concludes this author in an assessment of non-medical prescribing now, more than 15 years since district nurses and health visitors started to prescribe from a very restricted list.
Important systems and processes for non-medical prescribing include: ensuring students and designated medical practitioners (DMPs) understand the expectations of the prescribing programme; defining a prescribing role for each student when qualified; identifying clear criteria for going on the course; and putting support systems involving clinicians and managers in place.
Mental health nurse prescribing and understanding of medicines
October 17, 2010 by admin
“Previously unknown levels of incompetence” are revealed by the better understanding of medicines mental health nurses acquire when they become prescribers, argue the authors of this article, concluding by suggesting that there is a case for structured education in medicines management to be introduced into pre- and post-registration mental health nursing in the UK.
They use a variety of methods to come up with a theory that describes the process of becoming competent in mental health nurse prescribing, consisting of four themes that could provide a starting point for breaking down the skills nurses need to manage medicines safely. The authors highlight the sidelining of medicines management in mental health nursing, and how there is still debate over whether mental health nurses should be prescribing.
Snowden A and Martin CR. Mental health nurse prescribing: a difficult pill to swallow? J Psychiatric Mental Health Nursing 2010; 17: 543-553.
District nurse and independent prescribing
September 27, 2010 by admin
What is the experience of district nurses who are independent prescribers? This study explored this issue using interviews with eight district nurses practising as nurse independent prescribers in the west of Scotland. It found that their experiences were largely positive but identified a particular problem - which may be less of an issue for practice nurses - to do with administration and particularly duplicate record keeping (nursing and medical notes). This was of great concern and involved all sorts of difficulties to do with different locations, paperless systems and computer access. It is possible that the cumbersome systems were causing some nurses to limit their prescribing, although the authors point out that they were also relatively inexperienced as prescribers and lacked confidence (five expressed a lack of confidence in their prescribing ability).
Support - both organisational and peer - was a major issue too, with nurses reporting a lack of support from the time they qualified as prescribers: even when support mechanisms existed, they may be insufficient or inconsistent. As well as confidence and support, education and ongoing development, and nursing relationships and roles were identified as influences on prescribing practice. Other difficulties included an increase in workload associated with prescribing, partly because of the administrative issues, and a lack of remuneration and recognition.
Benefits identified by the nurses included saving time, a more seamless service for patients, and increased autonomy and job satisfaction, which supported the development of the district nursing role.
Downer F and Shepherd CK. District nurses prescribing as nurse independent prescribers. Br J Community Nursing 2010; 15(7): 348-352.
Consultations in diabetes care with nurse prescribers: patients’ views
September 20, 2010 by admin
Nurses prescribing for people with diabetes do so using the principles of patient-centred care, to the benefit of their patients, according to the conclusion of this study involving interviews with 41 patients with diabetes from the primary care case loads of seven nurse prescribers. Other benefits, for example improved understanding of treatments and conditions and improved self-care, seemed to result from the combination of a person-centred care approach combined with the additional knowledge and abilities of the nurse prescriber. Patients felt that continuity of relationships, flexibility over consultation length, nurses’ interpersonal skills, and specialist diabetes knowledge were all crucial. The authors argue that a number of related aspects of the nurse consultation style are coming together, enhancing patient care - in ways that may improve treatment decisions and adherence.
The extent to which patients wanted information about treatment options, or wanted to be involved in the decisions, varied widely and they were largely happy with the extent of their involvement. The provision of information about possible side effects seemed to be an area of inconsistency, however.
Stenner KL, Courtenay M and Carey N. Consultations between nurse prescribers and patients with diabetes in primary care: a qualitative study of patient views. Int J Nurs Stud 2010; in press. doi:10.1016/j.ijnurstu.2010.06.006.
Independent pharmacist prescribing in primary care
September 20, 2010 by admin
How can independent pharmacist prescribing be supported in primary care, as some pharmacist prescribers struggle to develop their roles and overcome barriers? In this interesting article, consultant pharmacist for cardiovascular disease Helen Williams describes how she works in primary care to develop prescribing roles for pharmacists, to convince GPs to commission pharmacist prescribing services - in the case of one of the new clinics, funding has now been taken over by a GP practice - and to support all prescribers. She describes how, for example, they have been able to demonstrate improvements in overall QOF achievements for blood pressure control in GP practices associated with the clinics she has been involved in setting up.
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.
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