Journals Watch 2000

This section features a constantly updated list of recently published articles relevant to nurse prescribing.

Abstracts of the papers are included and incorporate an expert's opinion about the article. Users are encouraged to submit their views about published papers through the feedback section.

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 Prescribing Formulary and Drug tariff if they are in any doubt.

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  • Continuing education crucial for prescribing nurses

Parker C. Nurse prescribing: basic and continuing education. Journal of Community Nursing 2000; 14:10-14.

Summary: The basic training that qualifies nurses to prescribe must not be the end of the story, according to this article. Equally important is the ongoing education of nurse prescribers so that their knowledge and appraisal skills are kept up to date. Nurse prescribers and their employers have a responsibility to update and extend their education about prescribing practice. Clinical governance requires that their care is satisfactory, consistent and responsive. In some areas of rapid product development in particular, it will be a challenge for nurses to keep up to date and they will need to evaluate product information critically. They will be subject to prescribing pressures from a variety of sources including pharmaceutical companies and will need to develop a sophisticated understanding of promotional activities.

Comment: The article highlights the importance of resources to help nurse prescribers keep up to date. The National Prescribing Centre website at www.npc.co.uk contains downloadable bulletins and nurse-prescriber will provide an electronic source of the latest information.

 

  • Prescribing for children

Stephenson T. Implications of the Crown report and nurse prescribing. Arch Dis Child 2000; 83:199-202

Summary: This article discusses nurse prescribing for children following the Crown report and the implications of the current licensing arrangements. A license is required by a pharmaceutical company for it to market and promote a drug but doctors can and do prescribe drugs that are unlicensed or are not licensed for that particular indication or age group (“off-license” prescribing). Unlicensed and off-license prescribing is common in paediatric practice. The Medicine’s Committee’s view is that other health professionals should be able to prescribe unlicensed and off-license medicines. The author sets out his view of the requirements for any professional to prescribe a medicine, whether unlicensed or not: the prescriber should have clinical involvement with the patient; should prescribe the correct dose; and should be aware of the side effects and advise on these in advance when appropriate. Additional steps to obtain the consent of parents or the child to prescribe unlicensed or off-license medicines should not be necessary. The formulary Medicines for Children sets out the consensus and authority for the use of unlicensed medicines and medicines outside their license. It contains consensus views on the correct drug doses for children of different ages for medicines where this information is not supplied by the company. This will be a very valuable resource for nurse prescribers. The author comments that nurses and pharmacists will be vulnerable to litigation in cases of error. For most nurses, the employer will retain liability but many community pharmacists are self-employed. One way of reducing the possibility of error would be to stipulate that all paediatric doses should be calculated on a palm top computer that automatically checks the prescription. A further safeguard would be to make all children’s drugs available in vials containing amounts suitable for children. A nurse faced with 100 vials of morphine to open would then be likely to realize that the dose was excessive.Then extension of prescribing for children to nurses and other professionals does provide an opportunity to improve the quality of care that children receive but it is vital that adequate resources are made available for training, implementation, monitoring, insurance and assessment.

 

  • Practice nurses offer effective minor illness service

Shum C et al. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. British Medical Journal 2000; 320:1038-1043.

Summary: Specially trained practice nurses in GP practices offered an effective service for patients with minor illnesses, according to the results of this study. Nurses and doctors wrote prescriptions for a similar proportion of their patients. The authors looked at the care given to 1815 patients requesting same-day appointments in five GP practices. They were randomly assigned to either a nurse or a GP and although nurses could refer to a GP, 73% of their patients were managed without any input from doctors. Clinical outcomes as reported by patients were similar. Patients were asked to complete a questionnaire to assess their satisfaction and these showed high satisfaction rates with both nurses and doctors, although nurse consultations scored more highly (mean scores, 78.6 vs 76.4, both out of 100). Nurses and doctors wrote prescriptions for similar proportions of patients: 65.4% for nurses and 63.5% for doctors. The nurse consultations were about two minutes longer on average.

 

  • Infrastructures needed to support nurse prescribers

Humphries JL and Green E. Nurse prescribers: infrastructures required to support their role. Nursing Standard 2000; 14:35-39.

Summary: A variety of infrastructures are needed to support nurse prescribing, according to the views of a group of health visitors and district nurses taking a nurse prescribing course. The researchers used focus groups to elicit the views of the 146 students. Ten themes emerged: protocols, keeping updated, peer support, patient records, project manager/managerial support, clinical supervision, GPs and other colleagues, pharmaceutical representatives, safety of prescription pads, and mechanisms for patients without a GP. The need to keep updated was seen as essential and a range of methods were suggested, including easy access to the internet and other computer-held sources of information, updates from the pharmaceutical advisors and/or community pharmacists, and funding for books and journals. Although these results should be useful in ensuring that effective infrastructures are developed, it may be that the participants’ views will change once they actually start prescribing.

For more information visit www.nursing-standard.co.uk

 

  • Implementing nurse prescribing

Thomas S. Nurse prescribing – the implementation process. Journal of Community Nursing 2000; 14. August issue

Summary: This article describes the background to nurse prescribing and gives a useful account  of the developments in policy, legislation and education so far. It concludes that nurse prescribing is really an inevitable consequence of the development of modern health care and that groups of nurses will continue to lobby the National Prescribing Advisory Committee.

For more information: www.jcn.co.uk

 

  • Establishing a community eczema clinic

Carey P, Darby J and O'Reilly J. Journal of Community Nursing 2000; 14. November issue

Summary: Three health visitors describe their experience in setting up a community eczema clinic for parents with children under five. They aim to educate parents about eczema and how best to manage it to improve quality of life for the children and their families. All three are nurse prescribers so they are able to prescribe emollients immediately. They aim to provide information about the different emollients available and how to apply them. They also provide information about topical steroids, wet wrapping and alternative remedies. After the first six months, they looked back at the initiative. All the feedback from parents and carers was positive, with the information about pathology and treatment of the condition being seen as most important. The health visitors were surprised at the number of inappropriate referrals they received. A major issue in compliance with treatment is personal preference of parents and carers, and this should be taken into account even when the preferred product is more expensive.

For more information: www.jcn.co.uk

 

  • Skin care for people with incontinence

Le Lievre S. Care of the incontinent client's skin. Journal of Community Nursing 2000; 14. February issue

Summary: Nurses, clients and their carers devote many hours to day-to-day skin care in cases of incontinence. How can nurses be sure that this is time well spent and how can they make decisions about the large range of incontinence and skin care products available? This article discusses the structure and function of the skin, the causes of incontinence dermatitis, and looks at ways in which nurses can minimize skin damage in incontinent clients. The author points out that nurses are in a good position to influence change and promote evidence-based care, particularly with the advent of nurse prescribing. More skin preparations are likely to be on the NPF in future. Because soaps are detergents they can remove natural protective oils and should be used with caution and avoided for people with dry skin, dermatitis or puritis. Barrier creams can sometimes cause skin problems or excessive hydration. Incontinence aids and appliances can also damage the skin: for example, latex sheaths can cause ulceration or constriction and plastic sheets can cause skin occlusion. The article makes recommendations with a view to keeping the skin as dry and in as near-normal condition as possible, and particularly considers the use of disposable body-worn pads, latex appliances and Foley catheters. There is evidence that pads containing super-absorbent materials reduce the wetness of the skin, maintain as near-normal pH as possible and also separate urine from faeces, minimizing the risk of the skin being irritated by faecal enzyme activity. The author stresses that nurses' care should be evidence-based, despite any financial pressures to consider inferior products.

For more information: www.jcn.co.uk

 

  • Diabetes nursing and nurse prescribing

Watkinson M. Editorial: is it our turn at last?; Padmore E. DSN prescribing under patient group directions: clarity needed; Vick C and Gardner P. Nurse prescribers: are they already out there? Journal of Diabetes Nursing 4: Nov-Dec 2000.

Summary: These three articles focus on the latest developments in nurse prescribing, how the government's proposals may affect diabetes nurses in the future, and how diabetes nurses should cope with the situation in the meantime.
Maggie Watkinson welcomes the suggestion that diabetes nurses could become nurse prescribers, allowing them to obtain the equipment and medication needed for good diabetes control much more easily. She points out, however, that given the timetable for amending the law about prescription-only medicines (POMs), insulin, oral hypoglycaemic agents and other POMS that diabetes nurse prescribers want to prescribe may not be included in the NPF by the time they are trained to do so. She also raises the question of who would train diabetes nurses about insulin regimens and dose adjustment, given that many of them are already involved in training both nursing and medical colleagues. The evidence base for insulin prescribing practice also needs to be examined. Although the consultation paper says that some nurses working in secondary care will be able to prescribe, the emphasis still appears to be on those working in the community. Eileen Padmore explains that there is uncertainty over whether DSNs can legally operate under patient group directions (PGDs), although the legal changes of August last year have clarified the situation for other groups of nurses using PGDs. The RCN and the Department of Health have apparently indicated that DSNs may not supply and administer POMs under PGDs, contrary to the advice they were being given before August. What should DSNs do now about the protocols that they were so recently being encouraged to use? The author asks whether DSNs should, "bury their heads in the sand and continue for the sake of our patients?", claiming that, "the entire diabetes service throughout the UK stands or falls on DSNs being able to supply, administer and adjust POMs". She stresses that diabetes nurses have been operating in a grey area for many years and have various ways around the situation, all with legal implications. In the current situation, the best advice is that the problem is discussed with key senior professionals in each trust and that decisions about altering or administering medication are well documented. Dosage adjustment does not seem to be a PGD issue but is related to local policy and accountability. A group of DSNs is looking into the possibility of taking the matter to judicial review, perhaps with backing from the industry. If a judge ruled that DSNs should be allowed to supply and administer POMs under PGDs, this would strengthen the legal basis for practice, until nurse prescribing is extended, and thereafter for those DSNs who do not wish to prescribe. Claire Vick and Phil Gardner summarize seven principle of good prescribing and ask whether an expanded NPF that includes POM treatments for diabetes is the way forward.

 

  • Nurses and emergency contraception: what pharmacists think

Cooper N et al. Pharmacists’ perceptions of nurse prescribing of emergency contraception. Br J Community Nursing 2000; 5:126-131.

Summary: Pharmacists do not have a consensus view about the role of nurses in the provision of hormonal emergency contraception (HEC), according to this survey of pharmacists. The prescription of HEC under protocol by pharmacists was more widely supported than that by nurses.
A 10% sample of members of the Royal Pharmaceutical Society was surveyed by written questionnaire and 1543 replied (a 38.6% response rate). Just over 30% disagreed to some extent with the statement that nurses should not be able to prescribe hormonal postcoital contraception, 42% agreed, and one-quarter did neither.
When respondents were asked to indicate which possible prescribing arrangements would be suitable, 41% thought nurses prescribing under protocol would be appropriate compared with 60% for pharmacists prescribing under protocol. Similar numbers approved of specialist trained prescribers from both professional groups but very few favoured prescription rights being extended across the whole group.
Overall, pharmacists seem to consider themselves to be more appropriate professionals than nurses to prescribe HEC. The authors discuss the implications of these findings, and the way in which professional roles may develop. They stress that nurse prescribing of HEC must be co-ordinated with other potential service developments. Although the survey predates the advent of OTC emergency contraception, the discussion is interesting.