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.

Policy, practice and education
Click on the article titles below to read the summaries.

• Changing roles and relationships
• Informal peer support crucial in nurse prescribing
• Do nurse prescribers feel more autonomous and independent?
• Practice nurses and prescribing: diagnosis and professional roles
• Working with GPs
• Nurse prescribing and pharmacology education
• Why nurses are reluctant to prescribe
• Preparing for the future of nurse prescribing
• What is PACT data?
• Patient group directions
• Pharmacists can learn from nurse prescribing
• The case for option five
• Practice nurses and nurse prescribing
• Patients’ views on nurse prescribing
• Principles of good prescribing
• Extending safe practice with PGDs
• Education crucial in prescribing
• Enhanced nursing: cost-cutting or improving patient care?

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• Working with GPs

Courtenay M. Practice Solutions. Nursing Times 2001; 97(43): 41

Summary: In this column, Molly Courtenay advises a nurse frustrated at the restrictions imposed by a GP on the already limited range of drugs that can be prescribed from the NPF. She points out that practice formularies can be very useful, particularly where the NPF includes many similar products with little in the way of evidence to differentiate them, and stresses the importance of good teamwork and communication. back

Website: www.nursingtimes.net

• Nurse prescribing and pharmacology education

Leathard HL. Understanding medicines: conceptual analysis of nurses' needs for knowledge and understanding of pharmacology (Part I); Understanding medicines:extending pharmacology education for dependent and independent prescribing (Part II). Nurse Education Today 2001; 21: 266-271; 272-277

Summary: These two papers examine what nurses need to know about pharmacology and how their pharmacological education could be extended for dependent and independent prescribing. They were written before the announcement about how nurse prescribing was to be extended, although they are very relevant to this development.

- What do nurses need to know?
In the first article, the author analyses the extent and depth of the understanding of medicines required for the following nursing purposes: patient care and support; pro re nata (as required; prn) administration of medicines; protocol-directed administration of medicines (dependent prescribing); independent prescribing from the current NPF; and independent prescribing from extended formularies or the whole BNF.

Under patient care and support, the author points out that it is not feasible for nurses to retain detailed information on a wide range of drugs but that they could be expected to have a comprehensive understanding of the medicines used often in their practice and know how to look up appropriate information about others. Three aspects of patient care and support require this: health education; correct administration of medicines; and early identification of adverse effects. After an explanation of brand and generic names, the author looks at the research available on pharmacology education for nurses.

Those nurses involved in prn medicine administration will need additional knowledge about, for example, regular compared with intermittent dosage, the signs and symptoms of under and over dosage, and perhaps the different modes of action if more than one medicine is available prn.

Prescribing under group protocol requires at least as much knowledge and understanding of pharmacology as prn administration and more if multiple drug use is specified or if the patients have additional continuing medications. In these cases, nurses will need to know actions and effects with some pharmacokinetic understanding, and will need knowledge of possible clinically significant pharmacodynamic or pharmacokinetic interactions between all the patient's drugs. The knowledge and understanding needed here, therefore, approaches that required for prescribing from extended formularies.

The pharmacological education required for the current NPF is very limited but further knowledge is required in two areas: integumentary and alimentary systems functioning.

As any extension of the NPF will include drugs that enter the systemic circulation, are distributed throughout the body and are subject to its metabolic processes, the author believes that anyone prescribing such drugs will need an extensive course in pharmacology and clinical pharmacology such as medical students currently receive. In addition to the above, understanding of the mechanisms of action will need to be at the level of receptor and enzyme interactions. Systemic factors that influence the concentrations and durations of actions in the circulation and target tissues will also need to be understood. The main aspects of drug discovery, development and evaluation should be understood, and the skills required for critical appraisal of trial data and promotional literature will also be needed.

- How can pharmacological education be extended?
In the second paper, the author describes the level of understanding needed of: classifications; actions and effects; duration of action and pharmacokinetics; interactions; and drug discovery, development and evaluation. The challenges for nurse education are discussed and some suggestions made about how to make pharmacology accessible.

Various combinations of therapeutic, pharmacological and chemical classification are used, but the author points out that pharmacological classifications can be particularly useful as they can be reminders of mechanisms of action and thus of actions and effects.

All prescribers need some understanding of the mechanisms of action of medicines. Understanding pharmacodynamics relies upon an understanding of the interactions between drugs and enzymes and between drugs and receptors. The author defines some important terms and explains how mode of action affects duration of action.

Turning to pharmacokinetics, a general understanding of the processes of drug distribution, metabolism and excretion will help understand safe frequencies of administration and provide a rationale for the need for caution with particular groups. Routes of administration, bioavailability, drug metabolism and excretion, and interactions are all discussed.
Nurses need an understanding of drug discovery, development and clinical evaluation to give them justified confidence in their effectiveness and safety, and an understanding of the role animal studies play, given that this debate is likely to continue.

In the author's experience, the greatest difficulty nurses face in increasing their pharmacological understanding is because of its foundations in chemistry. If nurses are to undertake reflective pharmacologically based practice, they will need to understand how medicines work in terms of physiology and pathophysiology and this will involve some chemistry and biochemistry. The author suggests that the chemistry required is fairly limited and suggests a range of analogies taken from familiar settings (revolving doors, salad dressings and so on) that can help educate nurses in basic pharmacological principles. back

• Why nurses are reluctant to prescribe

Campbell P, Collins G. Prescribing for community nurses. Nursing Times 2001; 97(28): 38-39

Summary: This article looks at why some community nurses who are qualified to take on a prescribing role are reluctant to do so, in the light of the announcement about the extension of nurse prescribing.

After a slow start to nurse prescribing, a tight timetable for the education of district nurses and health visitors was then imposed through funding limits, meaning that trusts had to release lots of their workforce simultaneously and individual students had little or no choice about when they went on prescribing courses. Many had to complete the open-learning element of the course in their own time. The timescale for the extension of nurse prescribing should therefore be considered carefully.

Some employers have altered job descriptions to include nurse prescribing, although there is a directive that it should be optional. The academic qualifications of staff involved in the initial roll-out varied, causing problems as the nurse prescribing education had to be at degree level.

Nurses' confidence in their diagnostic abilities is another issue: although nurses will not prescribe when they are not sure of the diagnosis, they should initiate treatment when they are sure. The expansion of the formulary must take place in the context of a fundamental belief in the skills and knowledge of nurses.

The paperwork involved in prescribing may mean that it is easier for nurses to ask GPs to write the prescription, another possible barrier to building confidence. All members of the primary care team should be involved in any agreement over practice-based formularies. As the formulary is expanded, employers may create restricted formularies, and nurse prescribers should have input into their composition.

All these issues should be addressed as nurse prescribing develops further. back

Website: www.nursingtimes.net

• Preparing for the future of nurse prescribing

Taylor B. Nurse prescribing - preparing for the next phase. Community Health Medicines Update 2001. July; 2-5

Summary: An appraisal of the options for the prescribing, administration and supply of medicines by nurses based on specific services could be useful over the next few months, given the key importance of local decision-making in the proposed extension of nurse prescribing. In this article, Beth Taylor, a Regional Principal Pharmacist, describes what is happening at present and sets out a guide for this appraisal. Questions that should be considered when looking at individual services are suggested and a guide to the possible advantages and disadvantages of five options - independent prescribing by a nurse, supplementary prescribing by a nurse, patient group directions, use of simple protocol (for OTC medicines), and referral to another independent prescriber) - is presented. back

Website: www.druginfozone.org/Publications/publications.html

• What is PACT data?

Maynard J. How to interpret PACT data. Practice Nursing 2001; 12:8-10

Summary: This article looks at how the mass of PACT data supplied by the PPA can be used to inform treatment decisions. It discusses how individual and practice prescribing costs are compared with health authority and national equivalents. PACT data from nurse prescribers is collected separately and is not dealt with here but the article still provides a useful explanation of how the system works. back

Website: www.practicenursing.com

• Patient group directions

Parker S. Interpreting patient group directions. Practice Nursing 2001; 12: 11-13

Summary: The use of patient group directions (PGDs; or protocols as they used to be called) became a legal requirement in August last year. They apply only to the supply or administration of medicines to patients who have not been seen individually by a doctor. They should not be confused with the issue of nurse prescribing and, in general practice, apply particularly to the administration of vaccines. The author, who is head of the nursing division at the Medical Defence Union (MDU), says that the MDU has received a number of calls about PGDs and that most primary care groups or trusts have taken the need to draft PGDs on board. She describes the circumstances in which PGDs should be used, what information they should contain for general practice, and which medicines can be included in them. back

Website: www.practicenursing.com

• Pharmacists can learn from nurse prescribing

The Pharmaceutical Journal 2001; 266:237

Summary: This leader argues that nurse prescribing offers pharmacy more of an opportunity than a threat. Progress towards pharmacist prescribing will also require careful planning, realistic goals, the support of other health professions, and clear aims that will result in better and more efficient services for patients. back

Giles S. Prescription for change. Nursing Standard 2001; 15:22

The UKCC Code of Conduct demands, amongst other things, that nurses acknowledge any limitations in their knowledge of competence and decline any duties or responsibilities that they are not able to perform in a safe and skilled manner. Option five allows nurses to work within this code, argues the author. back

Website: www.nursing-standard.co.uk

• Practice nurses and nurse prescribing

Warner J. Nurse prescribing. Practice Nurse 2001; 21(6); 18-20.

Summary: In this entertaining article, a practice nurse looks at how the proposals for the extension of nurse prescribing could affect practice nurses.
She points out that practice nurses are making decisions with patients about medication all the time but have to take the prescription to a GP for signature, even in areas such as travel health where they may be better informed. The present NPF is terribly limited given the remit of the work of practice nurses and the most radical option for extending it, option five, seems the most appropriate.
The issues that must be considered, however, include: possible increases in indemnity costs; costs associated with recording prescribing qualifications; relationships with pharmaceutical companies; and the need for critical scrutiny of studies supporting a particular drug. Should salaries and grades be modified to reflect the increased responsibility and training or will this create a divide amongst practice nurses with non-prescribers feeling second-class?
The author argues that the priorities, once training is available, will be seen as areas such as minor injuries and walk-in health centres rather than GP surgeries. The majority of practice nurses are unlikely to be included in the first wave. back

• Patients’ views on nurse prescribing

Brooks N et al. Nurse prescribing: what do patients think? Nursing Standard 2001; 15(17); 33-38.

Summary: A study involving 50 patients found that although many were unaware that nurses could prescribe they did think it was a practical and responsive method of service delivery.The patients were mainly low or new users of nurse prescribing whereas the health visitors, district nurses and the practice nurse were reasonably experienced. Several themes emerged from the qualitative interviews, with the majority expressing surprise that nurses could prescribe: only two patients had been told that their nurse could prescribe.Competence and training were felt to be important by the patients. The benefits identified included timeliness, with most patients receiving an assessment and prescription that day. The authors point out, however, that as some of these conditions might have improved on their own, this perceived benefit may have cost implications. Just under half the participants acknowledged that GPs’ and nurses’ time was better spent under this system and the same number thought that nurse prescribing was more convenient, with particular emphasis on care in the home. The quality of their relationship with the nurse prescriber was also seen as a benefit by some participants, who identified continuity, approachability, and the provision of information and reassurance. The practical approach of nurses was also seen as a benefit. Nurses were seen as experts on wound care, catheter care, nappy rash, mastitis, thrush, common complaints in mothers and babies, and dry skin/eczema. Participants also identified the nurses’ awareness of the limits on their professional expertise as a benefit. Sixty-six per cent of the participants were happy with nurse prescribing as it is at present. The other patients identified other areas where nurses could prescribe but only one thought that they should be able to prescribe the same range as doctors. An extension of nurses’ prescribing rights was seen as a benefit in terms of continuity. Training was seen as crucial here. back

Website: www.nursing-standard.co.uk

• Principles of good prescribing

Skinner J and Savage Y. Now you are a nurse prescriber – what should you do next? Nursing Times 2001; 97(23): 38-40

Skinner J and Savage Y. Now you are a nurse prescriber – what next? Nursing Times 2001; 97(24): 40-41.

Summary: In this article (the second in the series - see above) the authors look at the remaining four principles of good nurse prescribing. The fourth principle is to negotiate a contract and achieve concordance with the patient. This is partly about encouraging patients to engage in their care without shifting responsibility unfairly to them. The fifth is to review the patient regularly to secure the best outcome and safeguard nurses’ accountability. The sixth is to keep accurate and up-to-date records: prescribers need access to good technology but also need to develop their writing skills. The seventh is to reflect on your prescribing and here managers can help by providing both time and resources. The article concludes by suggesting that nurse prescribing is more about changing perceptions than a major change in working arrangements. back

Waters A. Patient group directions: a safer practice for nurses. Nurse Prescriber/Community Nurse 2001; 7(2): 31-32.

Some GPs remain concerned about their liability although they are happy for nurses in walk-in centres to use PGDs, as health authorities take the responsibility. If GPs will not sanction the development and use of PGDs, the author suggests some actions nurses can take: educate GPs (unless they are writing prescriptions for each treatment supplied/administered by the nurse, the nurse is breaking the law); contact health authority or board/trust; download a model PGD (see our links section) and get a doctor and pharmacist to help write one; and contact relevant drug manufacturers. back

• Education crucial in prescribing

Culley F and Courtenay M. Are nurses ready to prescribe without a doctor’s endorsement? Nursing Times 2001; 97(24):17.

Summary: Education is at the heart of this issue, according to both ‘Yes’ and ‘No’ sides in this debate. On the ‘Yes’ side, Fiona Culley argues that a holistic response to a patient could include prescribing the appropriate medicine, provided that the legal authority, skills, training and support are all in place. On the ‘No’ side, Molly Courtenay argues that current curricula for pre-registration training courses, with their emphasis on sociology and psychology, do not necessarily equip nurses with the knowledge of the life sciences that they need to diagnose and prescribe effectively. This issue must be addressed if the benefits of an extension of nurse prescribing are to be realized. back

Summary: Do enhanced roles for nurses (doing things that only doctors once did) provide real opportunities to improve patient care or are they a cost-cutting measures that threaten the core nursing tasks? Nobody can yet be sure whether enhanced nursing does save money. The Department of Health says that it has not attempted an estimate of any savings from nurse prescribing, for example. What evidence there is is not conclusive: some nurses earn more than junior doctors, nurses often spend more time with patients, but doctors are much more expensive to train. All these factors complicate the picture. It does, however, seem clear that enhanced nursing roles are improving patient care. back

• Do nurse prescribers feel more autonomous and independent?

Rodden C. Nurse prescribing: views on autonomy and independence. British Journal of Community Nursing 2001; 6(7): 350-355.

About three-quarters of the district nurses and health visitors participating in this study felt that their autonomy had increased since they started prescribing and two-thirds felt that they had become less dependent on their GP. Overall, 90% thought that nurse prescribing was a positive development and 80% believed their GPs supported it.
All 127 nurse prescribers in the Ayrshire and Arran Primary Care NHS Trust were sent a questionnaire to elicit their views on nurse prescribing and the response rate was 71% (90 questionnaires).
Many of the items in the original NPF relate to wound care, an area of specialist knowledge for district nurses, whereas health visitors focus on health promotion, particularly in young children. As expected, therefore, district nurses were found to prescribe much more frequently than health visitors but their views on autonomy and dependence did not differ significantly, nor did these vary with prescribing frequency.
In 48 answers, the nurses explained their views of the positive aspects of nurse prescribing: 18% identified saved time for the nurse, 22% felt their image and professional autonomy had improved, and 8% said that patient care was being delivered in a more effective environment. back

• Practice nurses and prescribing: diagnosis and professional roles

Baird A. Diagnosis and prescribing; The impact of nurse prescribing on professional roles and future practice. Primary Health Care 2001; 11(5): 24-26; 11(6); 24-26.

In these two articles, the author describes the results of some research exploring the implications of practice nurses’ current and future involvement in prescribing in a small sample of seven practice nurses and seven GPs in Sheffield.
The first looks at the issue of diagnosis, which is where the key difference between independent and supplementary prescribing lies. All interviewees acknowledged that nurses were already involved in diagnosis. In some cases this was covert, to avoid perceived challenges to GPs’ status.
Doubts about nurses’ knowledge base and training, as well as concern about mechanisms for verifying competencies, were expressed by both doctors and nurses. The responses of the nurses indicated that they saw their role in diagnosis as being clearly defined and confined to particular areas of expertise. This may be adequate for nurses involved in chronic disease management, where supplementary prescribing is likely to come in, and where clear boundaries and protocols are laid down. Nurses acting as first point of contact with patients with unspecified illnesses will need a broader knowledge base and may find themselves under the sort of real or perceived pressure that GPs do now to make a diagnosis in areas where they are not comfortable. The extent to which nurses’ training prepares them for such a role was an area of concern.
The author stresses that patient safety must not be sacrificed for political expediency or professional pride and highlights the need for a thorough educational programme that addresses the issue of competence in diagnosis and the issues raised by nurses’ involvement in it.
In the second article, she examines how the nurses and GPs saw their roles changing with the extension of nurse prescribing. Many of them saw these changes in the context of a shift in the balance of power and blurring of the boundaries between the roles of doctor and nurse. Some GPs were concerned that other GPs might feel threatened.
There was concern among GPs that their role as family doctor could be eroded, that they could become de-skilled, or that they would end up as a secondary provider, with only the more complex cases (two GPs said they would welcome this role).
GPs are usually the employers of practice nurses and this has implications for nurse prescribing. It means that GPs will be liable as employers for nurses’ actions although nurses will have to be professionally accountable, raising the question of where the burden of responsibility lies. There is also the possibility that, as employees, practice nurses could be asked to work outside their competencies.
The changes taking place in the NHS and particularly in primary care should be taken into account in extending prescribing to practice nurses. back

• Informal peer support crucial in nurse prescribing

Otway C. Informal peer support: a key to success for nurse prescribers. British Journal of Community Nursing 2001; 6(11): 586-591.

Informal peer support can compensate for the lack of more formal mechanisms for providing continuing professional development, according to the results of this study of 350 nurse prescribers.
The study was in a Trent trust which had piloted nurse prescribing so some of the nurses involved had been qualified nurse prescribers for more than three years. The first part of the study took the form of semi-structured interviews with 12 nurse prescribers. The results of these interviews were used to formulate a questionnaire which was sent to the 350 nurse prescribers employed by the trust and returned by 69%. The questionnaires requested mainly quantitative data.
District nurses were the most active and enthusiastic nurse prescribers, tending to prescribe 6-10 times a day. Health visitors and practice nurses, although they prescribed on average 1-2 times a week, were also positive about the benefits of prescribing for their practice.
Teamwork and peer support emerged as important factors: the more active prescribers tended to work in teams that included other nurse prescribers. They shared experiences and information, without regarding this as formal support. Conversely, isolation in practice seemed to be a negative factor and had not been overcome by any mechanisms of more formal support.
Of the 12 nurse prescribers interviewed, only two had regular formal clinical supervision. The benefits of clinical supervision were understood but it was seen as a luxury, dependent on staffing and workloads. At the time of the study, clinical supervision was being implemented in the trust, but not specifically to support nurse prescribing. Data from the questionnaires showed that 52% were undergoing regular clinical supervision, and 48% of these said it covered prescribing. As for mentoring, 95% of the respondents to the questionnaire said that they had not had a mentor when they started prescribing. Nonetheless, most described themselves as either confident or very confident in practice.
Although information was not collected on the extent to which the nurse prescribers considered themselves to be reflective practitioners, the ability to reflect on their practice and share experiences with their peers seems to have been crucial in the successful development of nurse prescribing. Unlike more formal mechanisms, it appears to remain available even at times of escalating stress and workload.
The author concludes by recommending that prescribing support forums, made up of an experienced nurse prescriber, a GP and a pharmacist, are set up in every primary care trust. The forums would ensure that skilled mentors, good informal peer support systems and regular clinical supervision systems are set up and that nurses prescribing in isolation have the necessary formal support. They should also have links with academic institutions to ensure that nurse prescribers receive excellent education and continuing professional development. back

• Changing roles and relationships

This article uses sociological and psychological concepts to examine how the introduction of nurse prescribing in Leicestershire altered the role of different professionals and the relationships between them. The tensions and insecurities that may accompany changes in roles are examined in this context. back

Website: www.jcn.co.uk