Policy, Practice and Education 2005

Please note: In this section of the website we aim to cover articles on areas where nurses do prescribe. However, not all the treatments or appliances mentioned are prescribable by nurses. For that reason, nurses should check the up-to-date versions of the Nurse Prescribers’ Formulary for District Nurses and Health Visitors (NPF) and the Nurse Prescribers’ Extended Formulary (NPEF) and Drug tariff if they are in any doubt. Alternatively contact your Regional Nurse Prescribing Lead for clarification.

General

Last update: 04/07/05

Click on the section titles below to read the summaries.

 

The approach taken by a large acute care NHS Trust to support and develop its new nurse prescribers is described in this article. It discusses the available evidence about the needs of nurses prescribers for ongoing support and development and the issues that face them in keeping up to date, and concludes that more research is needed.

The piecemeal approach to formulary extension, the limitations of the formulary, and the confusing way in which policy changes are sometimes announced, reinforce the need for nurses to be updated regularly and to have the opportunity to debate frustrations and work towards change. According to the author, a further issue at present is the possible misunderstanding and misuse of supplementary prescribing in providing the acute sector with a short-term fix to problems around overnight care and the reduction in the hours of junior doctors. Nursing organizations should develop robust policies to counter these influences.

Learning about the issues that nurse prescribers face in keeping their knowledge up to date and developing their confidence allowed the trust to start a forum for nurse prescribers. This functioned well for a year and then needed its structure and function to be revisited, given pressures of time, increasing numbers of nurse prescribers and the diversity of specialisms involved. It now involves quarterly meetings of 3.5 hours each, with attendance at three out of four in a year being compulsory for all trust nurse prescribers. The meetings are structured around sessions on continuing professional development (CPD), support on professional issues within prescribing practice, and a more formal business meeting.

The author suggests that a natural progression will be the development of more specialty-based networks to provide ongoing CPD and support. These would benefit from spanning primary and secondary care and including other groups of non-medical prescribers.

In a comment (p260), Helen Green responds to some of these arguments, pointing out that although supplementary prescribing was developed primarily for chronic illness, it is not restricted to it.
 

There is public support for nurse prescribing, according to one of the conclusions of this study into how community nursing is perceived by GPs, community nurses and members of the public.
All three groups agreed that community nurses must work in greater partnership with the public and most nurses felt that there was public misunderstanding about their role. The results indicated that there was a lack of clear understanding about the roles of community nurses and specialist nurses. Members of the public supported nurses prescribing, but GPs seemed less convinced and more than 40% of the community nurses also disagreed with the idea.
 

This article discusses the progress made on switching medicines for chronic conditions from prescription-only (POMs) to those that can be sold under the professional supervision of a pharmacist (P).

Nurse prescribers need to keep themselves up-to-date with the status of all medicines, according to Barbara Stuttle. Making medicines for minor ailments more available could also make better use of pharmacists’ skills.
There has been some criticism, however, of the decision last summer to make simvastatin 10 mg available without prescription for people at mild to moderate risk of heart disease. ‘The Lancet’, the consumers organization ‘Which?’, the Royal College of Pathologists and the Royal College of General Practitioners have all expressed concerns.
 

What sort of characteristics should a prescribing decision support system have? This article discusses how computerised prescribing software should be designed to improve patient safety, taking into account what is known about prescribing error. The author concludes that software design should: target high-risk drugs and patients; trap dosing errors (simple background programmes running all the time that display warnings if a dose exceeds half or twice the normal range); use standardised methods of production and evaluation; be congruent with good prescribing; focus on tasks that computers do well; make treatment individual; and develop programmes that prescribers enjoy using.

The author looked at 44 serious prescribing errors made by hospital doctors and concluded that more than half were inadvertent slips and somewhat fewer were “rule-based” mistakes (not knowing the correct rule). In addition, 4% were intentional breaking of the rules.
 

District nursing practice is being altered as a result of the introduction of nurse prescribing and other initiatives, according to the preliminary findings of this qualitative research into the way prescribing is changing relationships between district nurses and GPs, patients, carers, pharmacists, and other community nurses. Some relationships appear to have improved although others have worsened.

The research used semi-structured interviews with information from interviews being incorporated into the questioning of future interviewees. So far, interviews have only been conducted with nurse prescribers (number unspecified) in a variety of settings.

The additional administrative burden associated with prescribing seemed to be a problem for many nurse prescribers. In particular, for patients who are not registered with a GP, nurse prescribers do not have a GP account code for their prescription. This is being overcome in different ways but can create extra work.
Working relationships between GPs and nurses seem to be improving in some areas, with some nurses believing that GPs were happy with the arrangement as it lessened their workload and allowed patients to receive a quicker service. These may, however, have been relationships which were already working well before the introduction of prescribing and one nurse described a GP who expressed doubts about any expansion of professional roles.

The effect on relationships with non-prescribing nurses appeared to be variable, with relationships deteriorating in some cases, along with the standard of communication. Problems caused by requests from non-prescribing nurses for prescriptions for patients which the prescriber has not seen could be seen as part of a wider potential problem in which prescribing activity, and status of prescribing nurses, create divisions within the nursing workforce.

Individual comments about relationships with pharmacists, patients and carers are also included. In particular, it appears that nurses are still taking short-cuts by requesting supplies from pharmacists and writing up the prescription later. Further research will, it is hoped, look further into the apparent diversity in prescribing practice, the views of other groups affected by nurse prescribing, and the changing roles of community nurses and prescribing issues.

 

These two practice nurses conclude this analysis of their prescribing by identifying systemic antibiotics for all but a small group of conditions as the major omissions from the Nurse Prescribers’ Extended Formulary (NPEF).
They collected data over 6 weeks from 744 patients and found that they were able to complete episodes of care for 65% of patients. They issued 40% of the prescriptions during the period , and the GPs issued non-antibiotic prescriptions for 21% and antibiotic prescriptions for 31%. In total, 11% of the patients presented with upper respiratory infections, for which there are few medications available on the NPEF. The authors argue that they acknowledge concerns about inappropriate antibiotic prescribing but do not believe that limiting nurses in this way is the answer, pointing out that the practical ways nurses find to get round this may lead to a blurring of accountability.

The authors conclude that, within its limits, nurse prescribing is useful and effective but that nurses will continue to be prevented from completing episodes of care unless they can prescribe from the whole BNF according to competency.
 

These two articles examine recent legislative and policy developments affecting the supply and prescribing of medicines by optometrists. The range of prescription-only medicines (POMs) that can be supplied by optometrists is being extended and the emergency caveat for the supply of other medicines is being removed (see also here News item 136-3).

In addition, it seems that optometrists will soon be able to qualify as supplementary prescribers, although this perhaps should be seen as a route to gaining independent prescribers status in the future.
 

This small qualitative study found that that students preparing for extended formulary nurse prescribing found the objective structured clinical examination (OSCE), which is used in some institutions, to be stressful and anxiety-provoking. The literature suggests that the OSCE is of some value as a practical tool in assessing competence in extended formulary nurse prescribers. The author therefore suggests that the possibility of using the OSCE as a formative assessment and for constructive feedback and makes other suggestions for the future.
 

Non-medical prescribing and health visiting. Nurse2Nurse 2005; 4(11): 24-25.

The author reflects on the history of nurse prescribing for health visitors and highlights the characteristics of health visiting that mean that prescribing has the potential to form part of holistic patient-centred care. She notes that those health visitors who have extended their roles to include prescribing have done so without the benefits of extended and supplementary prescribing.
 

In this interesting article, the author describes her experiences of the training courses for independent and supplementary prescribing and the differences that prescribing have made to her practice. She found that her role changed little on becoming an independent prescriber, although her practice was now legal and validated.
Supplementary prescribing, for which she trained later, proved more of a challenge, with full support from the GPs needed, and initial attempts to implement CMPs proved time-consuming and cumbersome. They persevered, and developed a generic CMP template for patients attending an obesity clinic that allows her to prescribe orlistat. The system now seems to be working well.
 

This article provides an overview of some of the theoretical issues involved in nurse prescribing, looking at the legal and ethical aspects and at the NMC’s seven-step prescribing pyramid.
 

The author describes how GP practices can use their PACT data to analyse their prescribing practices, discussing the standard reports and PACT catalogues, as well as how electronic downloading offers additional flexibility in how the data are used.

PACT data do have limitations, in particular the lack of any patient or clinical information and the author explains how they can be used together with information recorded under the new GP contract to analyse whether prescribing is clinically appropriate. For example, with no patient data, it is not possible to say whether high prescribing rates for inhaled corticosteroids reflect overtreatment of people with chronic obstructive pulmonary disease or a high proportion of people with asthma on the practice list, all being treated appropriately. The contract data will provide prevalence figures for both conditions. PACT data can provide indicators of where inappropriate prescribing may be occurring but they represent a starting point only.

The influence of the pharmaceutical industry on prescribing decisions needs to be considered: nurses have been surprised by the interest shown in them as they assume more responsibility for prescribing decisions.

The author concludes that GPs, pharmacists, practice nurses and patients all need to work together using medicine management systems to improve the value for money we obtain from pharmaceuticals.
 

  • What is advanced nursing practice?
    Fairley D. Discovering the nature of advanced nursing practice in high dependency care: a critical care nurse consultant’s experience. Intensive Crit Care Nurs 2005; 21: 140-148.

Competent clinical reasoning, differential diagnosis and non-medical prescribing appear to be key functions of advanced nurse practitioners, according to the conclusion of this interesting discussion of the evolution of the role of a critical care nurse consultant’s role in a surgical high dependency unit in a large hospital trust. The key characteristic of advanced nursing practice, in a discussion of the research on this topic, was found to be the legitimate exercise of authority to develop autonomous practice.

Advanced nursing practice was seen more as an integration of medicine and nursing, with holistic nursing assessment combined with symptom-focussed physical examination, than as the acquisition and application of technical procedures usually done by doctors. The author discusses practical issues such as legal status, education, training, consent, and non-medical prescribing. The limitations of the Nurse Prescribers’ Extended Formulary were a factor in the author’s decision to postpone prescribing training and she favours nurses being allowed to prescribe from the full BNF. Supplementary prescribing and patient group directions will also be of limited use in this healthcare setting.
 

  • Prescribing generically
    Sprague D. Generics make sense for patients and prescribers. Practice Nurse – prescribing Nurse 2005; 29(10): 30-32.

Prescribers need to ensure that their prescribing practice is cost-effective as well as clinically effective, explains this author, and prescribing generic medicines can help with this. Generic prescribing can help communication, both because they are used internationally and because the generic name indicates the pharmacology of the drug, simplify the process of identifying a drug as proprietary names can multiply, and reduce costs.

The article explains how Prescription Pricing Authority (PPA) information about your practice and prescribing costs, with potential generic savings, can be useful, and also examines situations when generic drugs are not appropriate
 

In this short article, the author describes her first six months as a nurse prescriber, which have been largely positive, with increased job satisfaction, but with some frustrating restrictions and delays. These included difficulty in obtaining prescription pads, lack of electronic prescribing, pharmacists not being aware of supplementary prescribing, and the restrictions on antibiotic prescribing. She is making progress in overcoming these and welcomes the proposals to allow nurses to prescribe for any medical condition from a full formulary (see here and here).
 

Some qualified nurse prescribers appear to be continuing, or reverting to, their ‘non-prescribing prescribing behaviour’, or are failing to follow the ‘official’ nurse prescribing route in ways which risk perpetuating professional hierarchies, according to the preliminary results of this qualitative research involving semi-structured interviews with six district nurse prescribers. The low number of respondents has been the most difficult aspect of the project and the author hopes that offering group interviews will help.

The district nurses on the whole described a pragmatic approach to their responsibilities to document their prescribing actions, with some talking about continuing what was presumably their previous practice of filling in the details on the computer for the GP to prescribe rather than prescribing it themselves. Another described a situation where the GPs had requested that the district nurses did not ‘clutter’ up GP notes with nursing prescriptions. The GPs have therefore countermanded the legitimate process with their own interpretation, which raises questions both about the legality of the process and appears to indicate that the doctor-nurse hierarchy is still firmly in place. In addition, and importantly, these practitioners, by avoiding the ‘official’ route, may become deskilled in time.
 

Educational and training courses for independent nurse prescribers need to explore the concepts of evidence-based practice and research, and differentiate between them, and between evidence-based practice and evidence-based medicine. This was one of the conclusions of this small study of 16 experienced nurses, including some who were nurse prescribers and some who planned to become prescribers, using short answer questionnaires (16 responses) and focus group semi-structured interviews.

Nurse prescribers need to be able to understand the concept of evidence-based practice to provide medication management of high quality for their patients. The results of this study indicated that the nurses lacked confidence in the defining the terms above, and the author makes recommendations about future education and research.
 

Although community pharmacists appear willing and ready to work with nurse prescribers, increased contact leading to a greater understanding of roles will be needed if the potential of team working is to be achieved, according to the conclusions of this postal questionnaire survey of community pharmacists (mailed in January 2002).

Community pharmacists and prescribing nurses in the area had very low contact rates at this time, in contrast to those with other health professionals. The pharmacists had positive views of nurse prescribing and saw it is an important part of primary health care in the future. However, the limited contact reported does not provide a good basis for developing interdisciplinary working. Rapid organizational change in the healthcare system may set the conditions for interdisciplinary working, but attention needs to be paid to ensure the processes underpinning this develop.
 

This article describes a project in South West London to investigate the role of the nurse practitioner and to define its characteristics.

It emerged that there was perceived to be overuse of the nurse practitioner title, and confusion surrounding its meaning. A definition and list of competencies were developed and these have been adopted by local trusts, leading to better understanding of the role. The project used the 11 characteristics developed by the RCN, and added a twelfth, “having necessary registration to allow prescribing of appropriate treatment”.

Website: Nursing Times