Journals Watch 2002

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

Abstracts of the papers are included and 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 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.

Click here to visit the 2001 archive of Policy, practice and education

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

return to index

  • Importance of pharmacological education

Courtenay M and Butler M. Education and nurse prescribing. Nursing Times Plus 2002; 98(9): 53-54.

The authors highlight the importance of robust education programmes to prepare nurses for prescribing from the extended formulary, particularly in pharmacology (see 'Nurse prescribers want pharmacological training').

Nurses must have a clear understanding of all the products in the formulary and be able to use this in the context of a particular patient. To understand how medicines are administered and absorbed, nurses must also understand the related anatomy, physiology and disease processes. An understanding of the pharmacokinetics and pharmacodynamics of the products they are prescribing is crucial and the authors use the example of prescribing aspirin to show how this knowledge can be put into practice.


  • Managing minor illness

Pritchard A and Kendrick D. Practice nurse and health visitor management of acute minor illness in general practice. Journal of Advanced Nursing 2001; 36(4): 556-562.

Suitably trained practice nurses and health visitors can manage patients with a range of minor illnesses in general practice, according to the conclusion of this study, which found no difference in prescription rates between practice nurses, health visitors and GPs.

The training lasted three months. A list of eligible conditions was compiled, with protocols for treating them. Over 8 months in 1999, 2056 ‘urgent’ (within 24 hours) consultations were recorded: 13% were managed solely by a practice nurse or health visitor (for children under five), with the practice nurse/health visitor asking for the opinion of a GP during a further 5%. If the practice nurse or health visitor thought that a prescription was required, a doctor would sign it without seeing the patient.

Prescription rates, re-consultations, and referrals were similar for the three professional groups but GPs were more likely to initiate investigations. Patient satisfaction levels were good, with health visitor appointments scoring more highly than those with practice nurses or GPs.

 

  • Information sources for nurse prescribers

Courtenay M. Sourcing reliable evidence on medicines. Practice Nursing 2002; 13(2): 69-71.

More nurses in future will need access to evidence-based prescribing information, with the extension of nurse prescribing. In this article, Molly Courtenay discusses some of the available sources and stresses that practitioners must be able to identify, access and evaluate them.

The BNF, Drug Tariff, and National Prescribing Centre factsheets are all essential sources, but there are many others. The pharmaceutical industry, hospital drug information services and national pharmaceutical organizations all provide information. Vast amounts of material are available from the internet, although finding the relevant information and authenticating its quality can be difficult. Bibliographic databases such as Medline, can help as the articles have been published in quality-controlled journals. The full text of evidence-based topics can be found on websites such as Bandolier.

Visit the links section of nurse-prescriber.

  • Nurse prescribers want pharmacological training

Otway C. The development needs of nurse prescribers. Nursing Standard 2002; 16(18):33-38.

Pharmacological knowledge was identified as the most urgent training need, according to a survey of 350 nurse prescribers in a Trent trust (see related article, which describes the methodology and other results of the study – Informal peer support crucial in nurse prescribing).

The nurse prescribers seemed to lack confidence in their pharmacological knowledge and mentioned the role of the pharmacist in double-checking prescriptions, particularly when patients are taking several drugs. Of the 241 respondents, 80% wanted more pharmacological traning and 68% identified this as their most urgent training need. Although generally positive about the introduction of nurse prescribing, respondents were frustrated by the limitations of the current NPF.

The newsletter produced by the trust for nurse prescribers was the main method used for information dissemination. The nurses also read a range of nursing journals and some used the internet. Some GPs appeared to be acting as barriers to nurse prescribing and there seemed to be particular obstacles for nurses attached to dispensing practices.
The author again concludes by stressing the need for good support systems at two levels: organizational (prescribing support forums; internet access and IT training; local newsletters) and academic (modular post-graduate courses in pharmacology, diagnostic skills and critical evaluation skills; provision of mentorship and educational support).[back]

Website: www.nursing-standard.co.uk

 

  • Practice nurses may be prescribing outside the law

Jones RCM et al. The role of the practice nurse in the management of asthma. Primary Care Respiratory Journal 2001; 10(4): 109-111.

Practice nurses diagnosing and managing asthma are performing many duties previously undertaken by GPs, according to a survey of 179 respiratory nurses in Cornwall and Devon. Some may be undertaking prescribing that would be impossible to defend legally and professionally.

The nurses had all been identified as the practice nurse with prime responsibility for asthma management. They were initiating a range of treatments without consulting a doctor and displayed high levels of confidence in these activities. More than half were initiating treatment, without consulting a doctor, with inhaled bronchodilators, long-acting bronchodilators, and inhaled steroids. A small minority were initiating treatment with theophyllines and anti-leukotrienes and 15% were initiating treatment with oral steroids. About 80% of those performing asthma duties had received formal training but, surprisingly, there seemed to be no association between training and initiating treatment.

Many of the practice nurses were arranging for prescriptions to be signed without discussion with the GP. The authors point out that in the case of the 20% without formal training, and those who have not updated their training recently, they and their delegating GP could be vulnerable to criticism both from the professional bodies and from a court of law. The present NPF does not include any asthma medication. Nurse-initiated prescribing should only occur under clear and agreed shared care protocols.[back]

Website: www.gpiag-asthma.org

 

  • Community nurses and pharmacological knowledge

Sodha M et al. Nurse prescribing – testing the knowledge base. Journal of Community Nursing 2002; 16(3): 4-14

This sample of community nurses demonstrated a more comprehensive knowledge of prescription than OTC medicines, despite being frequently asked to advise patients about them. The results of the survey, designed to test the pharmacological knowledge base of community nurses, highlighted specific training needs.

Only 59 of the 212 questionnaires sent to health visitors, district nurses and community staff nurses in an inner city trust in 1999 were returned. None at that stage had received prescribing training or were working as prescribers. The nurses were asked to rate their own knowledge, confidence and experience in dealing with medication matters and were also asked to respond to three medication-related case studies.

The respondents identified areas of need for further training: drug management issues; drug dosage issues; specific drugs and their interactions; and pharmaceutical interventions for specific medical conditions. Nearly one-quarter of the sample rated their pharmacological knowledge as poor, nearly 60% as average and nearly 15% as good or excellent. The results from the case studies did not seem to correlate with self-rated knowledge or experience and did reveal some gaps in the knowledge base.

The authors conclude by suggesting that the information resources that community nurses access should be analysed and the scope for collaboration with other health professionals on medication-related matters examined.

Website: www.jcn.co.uk

 

  • Developing the nurse prescribing curriculum

Leung J. The extended nurse prescribing curriculum. British Journal of Community Nursing 2002; 7(3): 143-147

The author describes how the curriculum for the new extended nurse prescribing courses was developed (see article - "Outline curriculum approved by ENB" for curriculum content, duration and assessment methods).

Many of those involved saw the clinical pharmacology section as the most crucial: an understanding of how medications are absorbed, distributed, metabolized and secreted is vital for prescribing regardless of the type of medication. This section should not, however, overshadow the other areas of the curriculum and for some nurses and midwives it may be more a case of updating knowledge than starting from scratch.

The 12 days of supervision by a medical practitioner could take place in several different ways, including opportunities for the student to carry out consultations and discuss prescribing options with the supervisor.

 

  • Nurse prescribing: history and future

Parish C. Nursing Standard 2002; 16(28): 18-19

This article looks at how nurse prescribing has reached its current position, and discusses the prospects for its future expansion. RCN primary care policy advisor Mark Jones is quoted as saying that option five (from last year’s consultation on how nurse prescribing should be extended) will be reached by default, perhaps within two or three years. Once supplementary prescribing is working efficiently and effectively, there will be a transition from the supplementary to the independent formulary. He says that the government has adopted a “lowest common denominator” approach, in an attempt to maximise patient safety.

Website: www.nursing-standard.co.uk

  • Practice nurses and supplementary prescribing

Robinson F. Supplementary prescribing. Analysis. Practice Nurse 2002; 10 May: 13-14

Despite the broad welcome for the proposals about supplementary prescribing, there are concerns about their operation in everyday practice.

GPs do not welcome the extra workload involved in supplementary prescribing - mentoring of nurses and drawing up management plans - according to Dr Hamish Meldrum of the BMA GPs committee, quoted in the above article. He said that GPs would be calling for recompense for their practice and that although the proposals may provide a better service for patients, it has yet to be proved that they will save time. The BMA would like to have seen the scheme fully piloted.

The practicalities of drawing up individual patient management plans is also concerning Sara Richards, chair of the RCN Practice Nurses Association, who is quoted as saying that the plans have “been drawn up by bureaucrats who have forgotten just what it’s like working in general practice”. She believes, however, that once the system has settled down, it will benefit patients enormously.

Website: www.nursing-standard.co.uk

  • Nurse prescribing and change processes

Ridout S. Introducing nurse prescribing into a district nursing team. Journal of Community Nursing 2002; 16(5): 10-16

The theory and strategy of change in the implementation of nurse prescribing in a district nursing team are discussed in this article.

The author points out that it is important to be aware that the development of new services often involves changing professional roles, boundaries and loyalties, which can prove threatening. Professional groups may have different views or plans of the proposed change. The author discusses how change theory and analysis can be used in managing change.

Website: www.jcn.co.uk


  • Developing a minor illness course

Hughes A et al. A minor illness course for practice nurses. Primary Health Care 2002; 12(4): 18-20

GPs will need to provide time and support to make a nurse-led minor illness service a reality, according to the conclusions of this article about the development of a minor illness course for practice nurses in Gwent.

The six-month course combined distance learning with monthly study days. These covered: history-taking; physical examination; microbiology; nurse prescribing; role of GP mentor; and critical incidents. The course received university accreditation.

The benefits and challenges inherent in the new role are discussed here, along with the difficulties some nurses faced in completing all the course work and clinical practice in their own time. Protected time for the student and GP mentor is clearly needed, but can be hard to achieve.

Website: www.primaryhealthcare.net

 

  • Where is nurse prescribing going?

Jones M. Further and faster in nurse prescribing. Primary Health Care 2002; 12(5): 8

Much of Alan Milburn’s statement last month on nurse prescribing (see news item) has been welcomed by Mark Jones, RCN Primary Care Policy Advisor, but several knotty issues remain.

The request that the CNO draw up proposals to extend the range of drugs prescribable by independent nurse prescribers looks like good news, but what does it mean? The author hopes it is that all independent nurse prescribers will have a wider formulary, rather than that existing HV/DN prescribers will have access to the NPEF. Even so, there is a real danger that prescribing powers will be enmeshed in unnecessarily complex legislation.

When the Secretary of State said that it was his intention that every nurse who wants to and is trained to can prescribe appropriate drugs and medicines, did he mean as independent or supplementary prescribers? Are “appropriate” drugs those appropriate for the care of the patient, or those deemed appropriate by the legislators?

Mark Jones ends with a plea that the policy shifts in England will be reflected by similar moves in the other UK countries.

Website: www.primaryhealthcare.net

 

  • Nurse prescribing seen as “dangerous experiment”

Horton, R. Nurse-prescribing in the UK: right but also wrong. The Lancet June 1, 2002; 359(9321): 1875-76

The government should proceed with caution in extending prescribing rights, according to Dr Richard Horton, editor of The Lancet. He describes the policy as a “dangerous uncontrolled experiment” and says that nurses are being manipulated to fill the gaps left by the shortage of doctors.

“Prescribing is not a major advance in professional status for nurses. It is merely redrawing the boundaries of a profession to serve an acute political problem with little regard for the impact it will have either on nursing or patient care”.

To extend prescribing rights to all drugs in the BNF, as Mark Jones from the RCN has advocated, would mean nurses’ training becoming more like doctors’: should this be the future of nursing? Instead, Dr Horton suggests that what evidence there is about nurse prescribing points to more creative ways in which prescribing practices can be improved.
The reasons why doctors make mistakes when they prescribe have only just begun to be understood and Dr Horton argues that we need to understand more about why these errors happen before prescribing responsibilities are widened. The inclusion of black triangle drugs (recently licensed and subject to special reporting arrangements) under supplementary prescribing would, he argues, confer unnecessary risk to the patient. Nurses themselves seem to support a more careful approach.

He concludes by stressing that nurse prescribing has much to offer patient care and should not be allowed to “founder through hasty and politically expedient implementation”.

Website: www.thelancet.com

  • Pharmacological knowledge and confidence needs improving

Sodha M et al. Nurses’ confidence and pharmacological knowledge: a study. Br J Community Nursing 2002; 7(6): 309-315

The pharmacological knowledge base of community nurses in this study was not good enough to justify their levels of confidence in their prescribing abilities. There is an urgent need to increase this knowledge if they are to prescribe from a wider formulary, according to the conclusions of this article.

This follows a previous study of a small group of nurses (click here). In this larger study, 110 community nurses out of 183 returned questionnaires, designed to examine their self-rated knowledge and confidence levels in medication-related matters and their responses to five medication-related case scenarios. The respondents were health visitors, district nurses, community staff nurses, NHS Direct nurses, nurse practitioners and practice nurses. Forty-one, mostly health visitors and district nurses, were qualified as nurse prescribers.

Pharmacological knowledge was rated as poor to average by 83% of nurse prescribers and 90% of non-prescribers; 10% of non-prescribers and 17% of prescribers rated it as good to excellent. Some prescribers also rated their knowledge of medication-related matters such as legal responsibilities and the therapeutic effects of drugs as good to excellent (73% and 29%, respectively).

Prescribers were less likely to rate themselves as ‘not at all’ or ‘not’ confident in dealing with medication-related care, although this did not seem to be linked with the amount of time they reported spending on it. The DN/HV prescribing courses seem therefore to have increased the confidence levels of prescribing nurses.

However, the nurse prescribers performed less well than non-prescribers in answering the case scenarios, although neither group fared particularly well. For three of the scenarios, 82% 90% and 85% on prescribers gave an incorrect response or no response, compared with 60%, 63% and 51% of non-prescribers. The case scenarios were not directly concerned with items on the NPF. The respondents had particular difficulty with two OTC-related scenarios.

The authors stress that meeting the need for pharmacological education for nurses will not only build their confidence but go a long way to preventing medication-related errors.

 

  • Pharmacy bodies support supplementary prescribing

Wang L-W. Big response to prescribing proposals. The Pharmaceutical Journal 2002; 269(7206): 49-50

Although most of the bodies involved in pharmacy support the principle of supplementary prescribing in general, there are various concerns about how the system will work in practice, according to this article (see also news item about RCGP and RPS responses). The consultation has certainly generated interest: 622 responses had been received by the MCA one day before the consultation closed. Concerns focus on the lack of proper systems for dual access to patient records, the requirement that dispensing and prescribing remain separate, and training and its provision.

The National Pharmaceutical Association, for example, suggests that a patient-held smart card is the long-term solution to the records problem, but that patient-held notes should be introduced in the meantime. The ABPI is quoted as saying that without contemporaneous access to patient records, supplementary prescribing, even with retrospective recording, should not be allowed. The Dispensing Doctors Association shares its concern and says that without electronic systems for sharing and updating patient records, patients may be put at risk.

Website: www.pharmj.com

 

  • Legal implications of extended prescribing

McHale J. Extended prescribing: the legal implications. Nursing Times 2002; 98(32): 36-38

After a review of the history of nurse prescribing and the plans for extended and supplementary prescribing, the author considers their legal implications. Nurses have not been obvious targets for litigation in the past, but acting as sole practitioners and making clinical judgements may alter this position. Their increased responsibilities will include diagnosis and supply and determining capacity and consent, when administering medicines.

The government has said that if a nurse is acting appropriately as part of his or her professional duties, the employer will be vicariously liable if something goes wrong. Nurses are professionally accountable to the NMC and should have professional indemnity insurance. It is important that prescribers are confident that they have the necessary competence and knowledge for their role. Nurses adopting an extended role must be aware that they are likely to be held accountable if something goes wrong.

Website: www.nursingtimes.net

 

  • Safety and nurse prescribing

Blenkinsop A. et al. Staying safe when prescribing. Primary Health Care 2002; 12(7): 35-36

How can nurse prescribers in primary care organize their working practices to ensure that they prescribe safely? A systematic and consistent approach is important, argue these authors. Consistency will become part of the nurse’s clinical governance and will reduce the chance of errors of omission.

The consultation is central and requires a range of diagnostic, therapeutic and consultation skills. The move towards concordance, with prescriber and patient agreeing about a way forward, means that complex ideas and facts must be conveyed in an appropriate way for the individual patient. Doctors’ consultations are often criticized by patients.
Good practitioners must recognize that there is a chance that a diagnosis is incorrect and still manage the patient responsibly. Likewise, patients should understand that everything will not necessarily be settled in one consultation. Nurse prescribers should encourage patients to return if symptoms do not settle or change, noting that they have done so.

The National Prescribing Centre recommends several steps to good prescribing: possible questions; considering the appropriate strategy; considering choice of product; achieve concordance; regular review; accurate up-to-date record-keeping; and reflecting upon prescribing. The guidance in the BNF is invaluable in the production of an accurate, safe and legal prescription, for example about how to express quantities of drugs. The advice it offers about prescribing for specific populations such as children and older people is also useful.

 

  • Asthma and nurse prescribing

Weller T. Nurse prescribing: an update. Practice Nurse 2002; 24(4): 52-55

The author reviews the development of nurse prescribing so far and points out that although asthma nurses may be frustrated by the proposals for both independent and supplementary prescribing, the extended formulary does offer some opportunities.

Treating hayfever and rhinitis, which fall into the minor ailment category, can improve asthma control and smoking cessation advice and treatment is also important for this group.

Haigh S. How to calculate drug dosage accurately: advice for nurses. Professional Nurse 2002; 18(1): 54-57

The competence and confidence of nurses in making drug calculations has been a cause for concern. The user-friendliness of drug preparation and widespread use of electronic drip counters may have resulted in ‘de-skilling’. The consequences for patients can be serious if drug calculations are incorrect.

In June 2000, a UKCC council meeting expressed concern at the lack of basic maths skills among nurses: the risk of error was felt to be unacceptably high, particularly in paediatric nursing. The UKCC view is that calculators should not act as substitutes for arithmetical knowledge and skill. The author then looks at some common drug calculations and describes some simple formulae to help avoid errors.

 

Gregory S. Writing a prescription. Practice Nurse 2002; 24(5): 24-26

Prescriptions are potentially as powerful as operations and should be treated as seriously, according to the author of this guide to writing a prescription. The decisions should be rooted in sound clinical knowledge and the prescriber should be clear about the indication for the prescription and its necessity.

The author examines each step in the process of writing a prescription, considering contraindications, drug interactions, communication with patient and pharmacist, generic prescribing, dosing regimen and the use of computers. He concludes by stressing that any prescriber in doubt about the prescription they are writing should stop writing it and seek help.

 

Anderson P. Nurse prescribing: Assessing the data. Nursing Times 2002; 98(41): 43-44.

The National Prescribing Centre’s outline competency framework for nurse prescribers includes competencies relating to the appraisal and use of different sorts of information, and how information should be applied clinically. Deciding what constitutes good evidence, and finding it, may not be straightforward, given the maze of sources available to nurse prescribers.

This article points to some useful sources of good, quality-controlled, evidence such as Bandolier and discusses how material from pharmaceutical companies and the internet should be assessed. It also discusses how pharmacist and GP colleagues can help.

Website: www.nursingtimes.net

 

  • Using local formularies

Burrill P. Nurse prescribing: Local formularies. Nursing Times 2002; 98(42): 41.

Local formularies can help to improve medicines management and efficiency and, with guidelines, can drive appropriate and consistent good clinical practice, according to the conclusion of this article.

The author argues that prescribers need a more limited formulary than the BNF to allow them to make rational prescribing choices in nearly all the situations they are presented with. The selection of drugs for a formulary should be based upon the criteria of efficacy, effectiveness and efficiency.

Starting with data about current prescribing, and published evidence on efficacy, safety and cost, a formulary can be developed that includes recommended doses and simple directions as well as a list of drugs.

Website: www.nursingtimes.net

 

Courtenay M. An online educational website. Nursing Times 2002; 98(42): 42.

Training and education are crucial to the success of the initiatives to extend nurse prescribing. The website Nurse Prescriber has been developed to provide up-to-date information to those in the frontline. It now has more than 1500 registered users and qualified prescribers and those in training are finding it provides a valuable resource.

Website: www.nursingtimes.net

 

Smy J. Nurse prescribing. Training courses. Practice Nurse 2002; 24(2): 22-27.

This article looks at the experience of people on the first extended prescribing courses and discusses their future. Degree-level learning and the objective structured clinical examination will be new experiences for many practice nurses. Many of the first nurses to take the course may already have done nurse practitioner training, and will find these aspects less challenging.

At Kings College in London, a web-based course has been developed but the rules mean that students have to attend the college, even if they are sitting in front of the computer.

 

  • How nurses influence GP prescribing

Burns D. Nurses’ influence on GPs prescribing. Nursing Times 2002; 98(43): 41-42.

Nurses frequently influence prescribing in general practice, according to the results of this study. Although many of the participants were experienced practitioners who had undertaken additional post-registration education, none had received specific training in pharmacology or prescribing.

Of the 53 practice nurses contacted, 31 returned a completed questionnaire and 30 completed a diary about influencing prescribing. In one working week, 30 nurses reported 328 occasions when they influenced prescribing, covering 25 different clinical areas and 33 products. A small number exerted a high level of influence, despite apparently not having completed any recognized training programme in the clinical area concerned.

Additional training as independent or supplementary prescribers could be very useful for these nurses, giving them a detailed knowledge of the products involved, an understanding of the complexities and responsibilities of prescribing, and the capacity to take full responsibility for their actions.

Website: www.nursingtimes.net

 

Gregory G. Prescribing pitfalls. Practice Nurse 2002; 24(7): 14-19.

There were almost 1100 deaths from medication errors and adverse reactions in 2000. Although the strictly limited current formulary for independent nurse prescribing reduces the scope for major errors, it is well worth knowing the common prescribing pitfalls and trying to avoid them, particularly given the advent of supplementary prescribing and possible future expansion of the NPEF.
 
Common prescribing pitfalls can be described as: incomplete patient information; lack of drug information and poor communication. Lack of patient information is one of the most common errors. For instance, patients can be confused with other family members. So name, age and date of birth should all be checked, allergies should be checked with the notes and with the patient, and the possible presence of co-existing conditions should be considered. For drug-specific information, the BNF or MIMS should be consulted, but lack of up-to-date information can still be a problem. Despite the extra paperwork, nurses should make sure they are included in rapid drug warning systems.

Handwriting, incorrect or unsafe quantities, incorrect administration and the wrong date are all communication pitfalls. Nurses must currently write prescriptions by hand but using the computer systems as well gives the benefit of hidden cross-checks.

Finally, check the medicine is necessary, particularly if the patients is on more than four medicines.
 

Thomson C. et al. The value of research in clinical decision-making. Nursing Times 2002; 98(42): 30-34.

The internet, online databases, textbooks, locally compiled information files, and other library-based resources were not seen as useful sources of information to support clinical decision making, in this study of how research is used by nurses in clinical decision-making. Colleagues (and particularly clinical nurse specialists and link nurses) were found to be more useful and accessible.
 
Researchers at the University of York (Centre for Evidence-Based Nursing) used qualitative and quantitative data collection methods in three NHS trusts. Their methods included 108 semi-structured interviews, observation (180 hours) and audit (4000 documents). The only text-based resources accessed during the observation of nurses’ decision-making were the BNF, nursing and medical notes, and local protocols or guidelines. Nurses were seen using protocols or guidelines four times only, three on coronary care units. Only one-third of the 4000 documents examined referred to any kind of research evidence. Much was out of date, and badly organized, and there were nearly 1000 documents where it was impossible to identify the author(s).

Although nurses were positive about the contribution research could make to practice, they found it difficult to use it to inform decision-making. Various factors hinder the use of research including lack of confidence in interpreting and applying research evidence, the type of information, and workload and other organizational issues. The authors point out that the critical appraisal of research in nursing has not traditionally been taught well, if at all.

The article examines the shift towards an evidence-based practice culture and the importance of understanding the types of decisions that nurses make and their unanswered questions.

The authors look at how influential nurse colleagues such as clinical nurse specialists act as information intermediaries. They often stockpiled research-based materials, had extensive information networks, responsibility for teaching and disseminating research through the link nurse structures and in some cases critical appraisal abilities. They suggest that these nurses should be the focus of attempts to increase skills associated with evidence-based practice.

Website: www.nursingtimes.net

 

Topol A. Prescribing. Practice Nurse 2002; 24(8): 35-38.

Nurses prescribing for children and the elderly need to be able to tailor treatment to their patient’s needs as the published advice in formularies does not always apply to all groups. The composition of the human body changes with age and this and other factors need to be taken into account.

Children are often treated with unlicensed or off-license drugs because of the limited number of paediatric drug trials. Practitioners prescribing in this way must be able to justify their actions and take full responsibility for the outcome. In addition, there are pharmacokinetic and metabolic differences between children of different ages and adults that affect dosage and treatment choices.

The Royal College of Paediatrics and Child Health publishes a formulary called Medicines for Children which contains appropriate doses. A National Service Framework is currently being developed for children and this will tackle some of the complex issues around prescribing for children. Another issue for children is administration of medicines and the regimen should be tailored to suit the child and clearly explained.

The article then discusses prescribing for older people, looking at the way absorption, distribution, metabolism and elimination alter with age. The National Service Framework for older people includes milestones for prescribing and dispensing. Polypharmacy is often an issue for older people and they can be more susceptible to the side effects of drugs. Detailed medication reviews are important and the NSF sets out how often they should happen.

 

Crawford M. PNs are in the driving seat. Practice Nurse 2002; 24(8): 20-23.

The three strands of nurse prescribing – independent, supplementary and PGDs – will be merged eventually, says Mark Jones, now director of the CPHVA (formerly at the RCN), in this interview.

He thinks that the combination is cumbersome and will not survive, suggesting ways in which drugs can be moved from supplementary prescribing into the independent nurse prescribers’ formulary. PGDs are an area that need urgent attention, he thinks, and should really only be used in exceptional circumstances. Either PGDs should be altered so they can be used more widely, or nurses should be using independent or supplementary prescribing for tasks such as changing insulin doses, where PGDs are frequently used at present.

Another idea is for an education programme that will train nurses to recognize the limits of their competence so they can decide what they can and cannot prescribe, although he recognizes that guaranteeing that all nurses can do this would be hard. He also suggests that GPs and practice nurses will devise a number of care pathways that can be used for several patients in supplementary prescribing. The nurse prescribing qualification may become necessary for nurses in general practice, he suggests.

 

  • Three views on nurse prescribing

Burns D, Bulley R and Curphey P. Extended prescribing powers: three views. Nursing Times 2002; 98(44): 37-38.

A nurse, a doctor and a pharmacist all give their different views on the extension of nurse prescribing in this article. A golden opportunity to give nurses the tools to improve access to healthcare for their patients seems to have been missed, according to the nurse, Dianne Burns.

She argues that the limitations of the extended formulary means it will be of very limited use in primary care and many nurses may therefore feel the course would be a waste of time and effort. She also points out that vaccines are often supplied and administered under PGDs and using individual prescriptions for this would increase the workload. She doubts that the advent of supplementary prescribing will make a big difference to the way that practice nurses provide care for their patients, highlighting the time and effort involved in setting up individual clinical management plans. Without radical change, some nurses in general practice will continue to use existing mechanisms to provide medication for their patients.

The doctor, Roger Bulley, also foresees problems. Practice nurses are currently not well placed to take on nurse prescribing roles, because of a lack of funds or staff for backfilling. The Department of Health needs to address this urgently if supplementary prescribing is to take off. Communication, continuity of care and record-keeping, training and medico-legal and professional accountability issues are other areas that need addressing.

There are substantial and significant potential benefits for patients with the extension of prescribing responsibilities, according to the pharmacist, Peter Curphey. He stresses the need for caution, awareness of the limitations of personal knowledge, and the importance of consulting and interacting with the patient record. Integrated communications are needed, as is funding for training and replacement cover. Doctors, pharmacists and nurses need to co-operate, learn from each other and recognize one another’s expertise if the rewards are to be realized.

Website: http://www.nursingtimes.net/

 

  • Nurse prescribing debate in The Lancet

Correspondence. The Lancet 16 November 2002; 360(9345): 1607-1608

Nurse prescribing is currently the subject of a correspondence debate in The Lancet, following Richard Horton’s critique of the government’s plans (see “Nurse prescribing seen as dangerous experiment” article).

One US correspondent argues that the 37 days instruction is “grossly insufficient”, claiming that nursing evolves on the basis of society’s need, without much regard for the profession itself. The proposed training is contrasted with that received in the USA: nurse prescribing there is limited to advanced practice nurses and most of these have relevant master’s degree education. The nursing profession cannot afford to lower its standards so quickly and so easily, argues this writer.

Another correspondent, also from the USA, argues that the nursing and medical professions, although complementary, are almost entirely different, claiming that he or she would be as uneasy as seeing a well-trained and experienced nurse prescribing for a family member as at seeing an eminent doctor taking responsibility for daily living care.

Website: www.thelancet.com
 

Cook R. A brief guide to the new supplementary prescribing. Nursing Times 2002; 98(49): 26-27

The government’s plans for supplementary prescribing are explained in this article by Rosemary Cook, nursing officer at the Department of Health. Much of the material is based on the recent announcement (see here) but she does say that controlled drugs will be included once changes have been made to the misuse of drugs legislation. She also includes an example of a prescribing partnership for the care of a man with Parkinson’s disease.

Website: www.nursingtimes.net
 

Dean B. et al. Prescribing errors in hospital inpatients: their incidence and clinical significance. Quality and Safety in Health Care 2002; 11: 340-344

Keywords: medication errors; prescribing errors.

About 135 prescribing errors in a hospital each week were identified in this study which set out to investigate their incidence. Of these, 34 were potentially serious. Just over half the errors were associated with choice of dose. There was a higher error rate for medication orders written during a inpatient stay than on admission and discharge. Although a majority of errors originated in the writing of the medication order, over half the serious ones originated in the prescribing decision.

All prescribing errors were prospectively recorded by pharmacists for non-obstetric inpatients over a four-week period.
The authors conclude that knowing when and where errors are most likely to occur will help reduce their occurrence. Dr Bryony Dean, the lead researcher, is quoted in Nursing Times (10 December, p6) as saying that, “Supplementary prescribing may force doctors to document their decisions more and this should reduce errors……Nurses will be prescribing within their clinical specialties and this too could reduce errors”.

Website: http://qhc.bmjjournals.com/
 

  • Risks of medication during pregnancy and breast-feeding

Topol A. Drug risks: the unborn child and neonate. Practice Nurse 2002; 24(9): 20-26

Although about one-third of pregnant women in the UK may be prescribed medication, there has been little research into the effects of drug treatment during pregnancy and it can be difficult to assess the risks. This article looks at how drugs can affect the development of a fetus and at examples of proven teratogens. It also examines how drugs can pass into the breast milk, and possible effects on the neonate.

It concludes the all medication should be avoided in the first trimester except where stopping medication may prove a greater risk to the health of the woman and to her child. The mother should be given plenty of information about the choices, and drug doses should be kept as low as possible and used for as short a time as possible.
 

Nurse prescribing. General prescribing principles. Choosing a drug 1. Nursing Standard 202; 17(12): insert

This article examines the principles that should underpin practice for nurse prescribers choosing a drug. It points out that a thorough risk/benefit analysis is needed before any drug is prescribed or recommended: absence of harm is not enough.
 

Griffiths H and Jordan S. Corticosteroids: implications for nursing practice. Nursing Standard 2002; 17(12)

This article examines the use of corticosteroids to suppress inflammation, looking particularly at their adverse effects, drug interactions and optimising medication management. It covers a range of conditions, including some for which nurses may prescribe these agents.

Website: Nursing Standard