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.
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.
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.
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.
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.
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.
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
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.
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.
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