Practical Prescribing

Independent Nurse: Practical Prescribing

November 20, 2008 by admin 

Q: I work in a minor injuries unit. Since qualifying and receiving my prescription pad I have not yet written a prescription due to rules around controlled drugs that I did not realise existed. I thought restrictions only applied to Patient Group Directions, not prescribing. Could you advise?

A: In your full letter, you explain that, as an independent prescriber, you believed you would be able to administer adequate pain relief to patients under your care who present with severe pain after trauma and also cardiac chest pain. However, you have been advised by your lead nurse for non-medical prescribing that, because you are working in a minor injury department, this does not cover you to administer controlled drugs (CDs).

The CDs that a nurse can prescribe as an independent prescriber are linked to certain conditions and are as follows: diamorphine, morphine or oxycodone for use in palliative care;
buprenorphone or fentanyl for transdermal use in palliative care; diamorphine or morphine for pain relief in respect of suspected myocardial infarction or for relief of acute or severe pain after trauma including, in either case, post-operative pain relief; and chlordiaepoxide hydrochloride or diazepam for treatment of initial or acute withdrawal symptoms caused by withdrawal of alcohol from persons habituated to it.

Therefore, as an independent prescriber you can administer diamorphine or morphine for patients experiencing severe pain following trauma and also cardiac chest pain.

Regarding patient group directions, these can only be used to supply and/or administer diamorphine for the treatment of cardiac pain by nurses working in coronary care units and A&E departments. Therefore, as you work in a minor injury department, you would not be able to use a PGD to administer diamorphine to these patients. The results of a consultation that proposes the removal of the restrictions on the location which govern the supply/administration of CDs are currently awaited (1).

References
Patient Group Directions (MLX 336). MHRA

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Independent Nurse: Practical Prescribing

October 20, 2008 by admin 

I have just qualified as an independent supplementary prescriber and work in the area of palliative care. I have been told by my employer that I am unable to mix medicines for delivery in a syringe driver even if I am instructed to do so by a doctor. Is this correct?

Yes, this is correct – even though mixing of licensed medicines in the field of palliative care is long-standing accepted practice and there is evidence available that provides supports that this practice is safe. When this issue first arose, initial advice from a number of NHS bodies was that mixing of medicines could continue under the specific directions of a doctor or, if listed on the patients clinical management plan. However, further clarification from the MHRA has confirmed that under current legislation a doctor is unable to instruct a practitioner to mix licensed medicines and the use of supplementary prescribing is also inappropriate. Therefore, there are currently no circumstances in which medicines can be mixed by a palliative care practitioner.

As you will be aware proposal have been developed by the MHRA1 aimed at relaxing these legal requirements - comments for which must be submitted by the 13th February 2009.
Four options are proposed in this consultation; however, support is given to Option D which would enable Nurse and Pharmacist Independent Prescribers to prepare products for their patients and also direct nurses and pharmacists non prescribers to mix drugs prior to administration. Doctors would also be able to direct nurses and pharmacists to mix medicines.

1) Public consultation (MLX 356): Proposals for amendment to medicines legislation to allow mixing of medicines in palliative care

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Independent Nurse: Practical Prescribing

September 20, 2008 by admin 

I am a Nurse Practitioner. Our PCT is asking non-medical prescribers to complete a detailed Performa including information of the sections of the BNF from which we prescribe, and evidence of education and competence. This information is required to be updated annually. Can this be enforced?

If this is policy, you must work within it. The NMC CPD guidance for prescribers (1) recognise that appraisal of CPD needs should be undertaken annually as part of performance review and preferably using a recognised tool such as the NPC NIPEC tool. This will identify the level of CPD you require in order to demonstrate competency to meet education and practice needs. You are also required to keep a portfolio that demonstrates CPD and your ongoing needs. Although you are responsible for your own CPD needs, your employer must support you in addressing them. What you are being asked to do, ‘fits’ with this guidance.

Some nurses list the areas in which they prescribe as an ‘intent to prescribe’. They say that this is helpful document to which to refer if asked to prescribe outside of their area of competence. However, they also say that to have anything to rigid in place restricts practice i.e. as competencies develop, these areas extend. A discussion with your manager about this might be helpful. Hopefully, you would be able to add to the Performa as your area of competence grows.

As a Nurse Practitioner your area of practice will be vast and so difficult to list all the categories of medicines that you prescribe along with associated CPD evidence. A group of Nurse Practitioners in Bradford are currently in the process of completing a local appraisals pilot, involving the collection of robust evidence demonstrating performance. Ghislaine Young (ghislaine.young@bradford.nhs.uk) is the person you need to contact.

1) NMC. Guidance for CPD for Nurse and Midwife Prescribers NMC circular 2008 10/2008

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Independent Nurse: Practical Prescribing

August 20, 2008 by admin 

I am a community matron working within a 5 practice locality. One of the practices has requested that I don’t prescribe for their patients, but instead, ask the practice to prescribe if any patient requires a prescription. Where do I stand if I want to go ahead and prescribe anyway?

Nurses employed by a PCT may only issue a prescription for the patients of GP practices within the PCT. Additionally, if they are providing services through a community nurse prescribing contract, they can issue prescriptions for the patients of GP practices covered by the contract and for which a prescribing budget has been agreed. Community nurses covering a number of practices, such as yourself, can use one prescription pad but, must complete the relevant Practice Code Number for the individual patient. The prescribing expenditure that you incur is then charged to the GP practice on whose behalf you prescribe.

It is not clear from the information that you have provided, why, 1 of the 5 practices within whose locality you work has requested that you do not prescribe. The success of prescribing is dependent upon the ability of healthcare professionals to work together as a team. Therefore, you need to address this with the practice in question and your manager. It would also be a good idea to contact your prescribing adviser. It could be that the doctors in the practice do not understand nurse prescribing. They may feel anxious for example about your assessment and diagnostic skills or, that you will prescribe outside of your area of competence. A meeting with the doctors of the practice in question would provide you with the opportunity to discuss with them the benefits of your role, any anxieties they may have and allay any fears. I am sure they would find a copy of the NMC Standards of Proficiency for nurse and midwife prescribers (NMC 2006) useful. Good luck!

Reference
NMC (2006). Standards of Proficiency for nurse and midwife prescribers. London: NMC

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Independent Nurse: Practical Prescribing

July 20, 2008 by admin 

I am a qualified Nurse Independent/Nurse Supplementary Prescriber. I am planning to change career direction and move into the blood transfusion service. Would I be able to use my prescribing qualification in this area?

Blood and its cellular elements e.g. packed cells and platelets are not classified as medicinal products and so therefore it would be inappropriate for you to use your prescribing qualification to prescribe them. It is also inappropriate to supply or administer blood or its cellular elements using a Patient Group Direction. However, appropriately trained, competent practitioners (including nurses) can order, authorize, and administer blood. Therefore, provided you developed your knowledge and skills in this area, there would be nothing to stop you from doing this. You would need to discuss the policies surrounding this with your employer. Work looking at the necessary educational preparation to order, authorize, and administer blood is currently underway between the NHS Blood and Transplant (NHSBT) and the Scottish National Blood Transfusion Service (SNBTS). However, it is important for you to appreciate that you would not be using your prescribing qualification in this role. Obviously, you could use your prescribing qualification if medicines were required to be prescribed alongside blood e.g. frusemide. You could also prescribe unlicensed medicinal products derived from the plasma component of blood (e.g. blood clotting factors) under supplementary prescribing and using a Clinical Management Plan. You could prescribe licensed plasma substitutes independently.

Obviously, before you start using your prescribing qualification in the blood transfusion service, you need to develop the necessary competencies. The prescribing competency framework, developed by the National Prescribing Centre (NPC),1 will help you identify these competencies and your continuing professional development needs.

Reference
1) NPC (2001). Maintaining competencies in prescribing- an outline framework to help nurse prescribers. Liverpool: NPC

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Independent Nurse: Practical Prescribing

June 20, 2008 by admin 

I am a diabetes specialist nurse and dose adjust insulin for my patients under a Patient Group Direction (PGD). Is this acceptable? I am concerned that my manager will want me to undertake training to prescribe. However, I do not want to do this because of the amount of study required.

The dose adjustment of medicines under a PGD is acceptable. However, legislative criteria require that the dose or maximum dose is specified i.e. it is necessary for the PGD to clearly identify a single dose or a range up to a specific maximum dose. Both the doctor and the pharmacist who sign the PGD must be satisfied that the dose range that is specified is clinically appropriate. It is also necessary that the clinical criteria for selecting a dose within that range are specified. Those using a PGD in this manner must be competent to make the decision on dose.

The specifications required if using a PGD for dose adjustment are very rigid and so may well not be of use to the practice of some nurses, for example, if major dose changes are required.
In addition, PGDs were not designed to cover long-term therapy for chronic disease management. Nurse prescribing, and the greater autonomy that this role provides, would resolve these issues. However, prescribing is not for all nurses. With autonomy comes greater responsibility and some nurses do not want this. Some nurses, like yourself, do not want to undertake the training programme because of the amount of study that is required. Indeed, the implementation guidelines for prescribing (Department of Health (DoH) 2006) state quite clearly that nurses should not be nominated for this training unless they want to prescribe. It would therefore be inappropriate for your manager to make you feel pressurized to undertake the prescribing course.

References
DoH (2006) Improving patients’ access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England. DoH, London.

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Independent Nurse: Practical Prescribing

May 20, 2008 by admin 

We are a team of nurse practitioners prescribers working for a social enterprise company. We currently work for a PCT providing in and out-of-hour’s primary care. Occasionally we supply medication direct to patients. The PCT has supplies of common antibiotics etc either stored in our car or at base. Sometimes these supplies do not equate to the course and we label the drugs ourselves. What is the difference between supplying and dispensing? We believe the procedure for the storage of medicines, both at base and in the car is unsafe. We have discussed this with the relevant manager and some changes have been made, however, we still feel things are unsafe. A follow-up audit has been promised. How do we stand legally and professionally whilst maintaining a duty of care to our patients?

As you are labelling the medicines from a stock supply that is then administered to a patient, you are dispensing. Wherever possible, nurse prescribers should ensure the separation of prescribing and dispensing (NMC 2006). In exceptional circumstances where nurses are involved in both activities for a patient, a second suitable competent person should be involved in checking the accuracy of the medicine provided. Within the context of the situation you have described, this could be a patient or a relative.

As your car is being used to transport medicines, it should be insured for PCT business purposes. Medicines should be transported in your car in a cool, dry, lockable container, out of sight, in your boot. Medicines should not be stored in your car but in a secure, locked cupboard located in a cool area (or fridge if appropriate) at base. As long as you are working within the policy of the PCT, you are practicing legally. However, you should raise any concerns at the follow-up audit.

Reference
NMC (2006). Standards of Proficiency for nurse and midwife prescribers. London: NMC

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Independent Nurse: Practical Prescribing

April 20, 2008 by admin 

I am a student on the prescribing programme and work in an elderly care setting. In order to successfully complete the course, I have to demonstrate my competence in relation to history taking and assessment in children. Can you explain this outcome as it bears little relevance to my area of practice?

Many nurse prescribers work in settings in which they regularly come into contact with children. The NMC have developed an additional learning outcome for the prescribing programme that strengthens the ‘Standards of Proficiency for Nurse and Midwife Prescribers’ (NMC 2006) in relation to prescribing for this group.

The NMC Standards of proficiency make it clear that only nurses with the relevant knowledge, competence, skills and experience should prescribe medicines for children. Anyone prescribing for children (e.g. nurses in walk-in-centres) must be aware of their area of competence for these patients and know when to refer if working outside of their area of expertise.

As a means of strengthening this Standard, the NMC now require student prescribers to demonstrate that they are aware of the anatomical and physiological difference between children and adults, are able to take an appropriate history and clinical assessment, and make an appropriate decision to diagnose or refer.

The above assessment should take place within the context of the students work setting. As you work in an elderly care setting and do not see children this would not be possible. Therefore, the above assessment may be demonstrated in your portfolio. It might be that in the future you take up a position working in a primary care setting in which you will be required to prescribe for children. By demonstrating knowledge in the areas outlined above on the prescribing course, you will be able to recognise if you require further education and training in children prior to taking up such a post.

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Independent Nurse: Practical Prescribing

March 20, 2008 by admin 

I have been qualified as a Nurse Independent/Nurse Supplementary prescriber for 18 months and prescribe regularly. Do I need to undertake additional continuing professional development (CPD) as a prescriber? How do I identify my CPD needs? What forms can this CPD take? Is it my responsibility to meet these needs?

The Nursing and Midwifery Council (NMC) have recently published guidance for CPD development for Nurse and Midwife Prescribers.1 This guidance proposes that prescribers are not required to undertake additional hours of practice to meet CPD requirements as prescribing is part of professional practice. It is proposed that appraisal of CPD needs for prescribing should be undertaken on a yearly basis as part of performance review, preferably using a recognised tool such as the “Maintaining Competencies in Prescribing Framework” developed by the National Prescribing Centre (NPC).2 Such an appraisal should identify your CPD requirements in order to demonstrate competency, to meet both educational and practice needs. The NMC also propose that prescribers keep a portfolio of evidence demonstrating, through reflection, both CPD undertaken and ongoing learning needs.

Although you are responsible for your own CPD, your employer should ensure that where you have recognised CPD needs, they support you in meeting these needs. This CPD should suit your individual learning style, can be accredited through a range of institutions (including higher education institutions, professional bodies, and prescribing forums) and can take the form of e-learning, journals, prescribing forums, individual study, work-based learning, formal CPD days, and Action Learning Sets.

You mention that you prescribe regularly. The practice requirements proposed by the NMC is that prescribers make assessments and undertake prescribing decisions (this need not necessarily result in a prescription) regularly in order to maintain registration. The hours spent in prescribing or making prescribing decisions should be counted as CPD. The theory requirement is that you are up-to-date with evidence based practice and “Best Practice Guidelines”.

1) NMC. Guidance for CPD for Nurse and Midwife Prescribers NMC circular 2008 10/2008

2) NPC. Maintaining competencies in prescribing- an outline framework to help nurse prescribers. Liverpool: NPC 2001

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Independent Nurse: Practical Prescribing

February 20, 2008 by admin 

I was asked by a consultant to prescribe a medicine for a patient I had not assessed, and for a condition outside of my area of competence. I did not prescribe but don’t want this situation to arise again. Can you advise?

It is important to understand why you have been asked to prescribe outside of your area of competence. Amongst some member of the medical profession there is a lack of understanding about nurse prescribing. This has led to doctors feeling concerned about nurses encroaching on medical territory, nurses’ clinical skill base, and the possibility that nurses will prescribe outside of their area of competence. The rapid expansion of nurse prescribing in the UK has done nothing to allay these anxieties. However, if nurse prescribing is to be successful, the support of doctors is crucial. A lack of support by doctors has been identified as a barrier to nurse prescribing! The support of a medical prescriber is a necessary pre-requisite for prescribing training; they provide essential and invaluable support during the prescribing course and essential supervision post qualifying.

It seems that the consultant in question does not fully comprehend nurse prescribing. I have heard stories of unconfident House Officers almost being coerced into prescribing by their Consultant colleagues. In nursing, this situation would never occur. A nurse runs the risk of losing their registration if they prescribe outside of their area of competence. You need to educate your Consultant colleague about the professional limitations of nurse prescribing and, promote and publicise the NMC Standards of Proficiency for nurse and midwife prescribers (NMC 2006). This should provide the necessary reassurance that nurses (perhaps unlike the medical profession) won’t prescribe outside of their area of competence. Once this is understood, the situation you have described will not arise again.

Reference
NMC (2006). Standards of Proficiency for nurse and midwife prescribers. London: NMC

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