Journals Watch 2003

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.

2002 PPE | 2001 PPE

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

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Luker KA and McHugh GA. Nurse prescribing from the community nurse’s perspective. Int J Pharm Pract 2002; 10: 273-280

Around one-quarter of nurses qualified to prescribe from the DN/HV formulary are not doing so, according to the conclusions of this study, which argues that infrastructures and mechanisms to support nurse prescribing have been slow to emerge.

The study took the form of a questionnaire survey to qualified DN/HV prescribers in three UK Primary Care Trusts. Of the 164 mailed, 129 were returned (79%), with 93 (72%) from prescribing nurses being used as the sample.
For district nurses, prescribing costs for a 12-month period were between £7.65 and £18,053 (median £2023.64) and for health visitors from £0.73 to £2556 (median £42.77). Despite being trained, 28 of the nurses had decided not to prescribe.

The nurses did think they were providing better care and gave a cautious welcome to the extension of nurse prescribing.
 

Granby T. Lessons learnt from the nurse prescribing experience. The Pharmaceutical Journal 2003; 270(7230): 24

Opportunities to prescribe regularly, and robust continuing professional development infrastructures, are needed if pharmacists are to be able to prescribe safely and effectively, according to the conclusion of this article. Trudy Granby is the nurse prescribing support manager at the National Prescribing Centre and this article suggests ways in which pharmacists can avoid some of the pitfalls of the nurse prescribing roll-out.

The Prescribing Support Unit figures for October 2002 show that 11,100 nurses were actively prescribing in England, out of around 21,700 qualified to prescribe from the NPF and 400 from the NPEF. Many factors could account for this, education and training among them. Partly because of the guidance current at the time, some nurses were trained to prescribe from the NPF who would have little or no opportunity to do so in practice. In contrast, selection criteria for extended independent nurse prescribers in England now include identification of service need and patient benefit. The much more detailed outline curriculum for extended independent nurse prescribers, the NPC’s framework of competencies for nurse prescribers, and the 12 days of learning and assessment in practice should also mean that the preparation is more consistent, targeted and practical. The framework may also be helpful in training needs analysis, ensuring that CPD meets the needs of nurse prescribers, and does not merely reflect what is available locally.

Website: The Pharmaceutical Journal
 

1. Wilson P. The development of a curriculum for supplementary prescribing. The Pharmaceutical Journal 2003; 270(7230): 21-22

2. Adcock H. Establishing training for pharmacist prescribing will be a challenge for 2003. The Pharmaceutical Journal 2003; 270(7230): 7-8

What training will be necessary to become a supplementary prescriber and what will be the role of the Royal Pharmaceutical Society as the regulatory body? After posing these questions, Peter Wilson [1](the RPS’ consultant on continuing professional development) describes the curriculum content and learning outcomes.

Pharmacists will be entering the training from a variety of backgrounds and with different types and levels of expertise. Programme providers can make appropriate allowances for this by including directed private study, although there will need to be a significant element of class time. Pharmacists will need the opportunity to acquire new knowledge and skills in areas such as pathophysiology, disease progression, physical examinations and monitoring responses to treatment.

Pharmacists will also need to spend at least half a day a week in clinical practice supervised by a doctor, learning among other things to prescribe for the conditions for which they will be taking responsibility as a supplementary prescriber, to get experience working in a team and to examine patients to monitor responses to treatments. This clinical experience is crucial for patient safety.

The RPS will probably need to accredit prescribing courses and help with quality assurance of pharmacist supplementary prescribers. Continuing professional development and revalidation will also need addressing. In time, undergraduate degrees are likely to include prescriber training.

The timescale of the proposed rollout of pharmacist supplementary prescribing, with the government expecting training courses to start on the spring, presents a challenge, points out Harriet Adcock [2], especially as the final shape of the courses has not yet been decided. Although the training costs themselves will be met centrally, the need to work out locally how to cover extra expenses such as locum fees is likely to prove troublesome.

It seems that feedback from pharmacists has been positive, despite the challenges involved. In one of the Department of Health road shows about supplementary prescribing, all discussion groups apparently came back saying they definitely wanted to do supplementary prescribing, because of the benefits to the NHS, patients and the profession. They identified potential problems as: access to patient records, identifying suitably experienced mentors and engaging independent community pharmacists.
 

Bullock S and Manias E. The educational preparation of undergraduate nursing students in pharmacology: a survey of lecturers’ perceptions and experiences. J Advanced Nursing 2002; 40(1): 7-16

A number of the lecturers surveyed in this study were dissatisfied with the pharmacological knowledge base and preparation of nursing graduates in Victoria, Australia. The lack of integration between pharmacological theory and practical knowledge was also of concern. The number of hours devoted to pharmacology and the stage of the course at which it was offered varied.

The authors concluded that a curriculum review is required to improve the knowledge base of students and improve life-long learning skills. This would contribute to increased confidence in nurses assuming prescribing responsibilities. They also comment that the UK literature suggests a perception that teaching time on biological sciences has been decreased in favour of an enhanced psychosocial perspective and that a number of researchers have been pressing for curricular review in the UK too.
 

Adcock H. How will pharmacists training to be prescribers be supervised in practice? The Pharmaceutical J 2003; 270:46

How will the requirement that pharmacists training to be supplementary prescribers undergo supervised practice be implemented? This article looks at the possibilities.

The minimum time requirement will be 12 days, probably because many pharmacists are not skilled in physical examination and have a limited knowledge of pathophysiology. Dr Peter Wilson, consultant to the Royal Pharmaceutical Society on continuing professional development, explains that this period will allow the theory gained from the training programme to be put into practice and the necessary practical skills to be learned. Pharmacists will be learning to monitor patients for the specific conditions for which they will be prescribing.
Finding doctors with the appropriate skills and time to take on the supervising role will require advance planning, according to Clive Jackson, chief executive of the National Prescribing Centre, with teaching practices in a better position to deliver support. GPs and hospital doctors must be convinced of the benefits of supplementary prescribing by pharmacists if it is to take off, as their support is vital.
The article also reports the experiences of a GP who is supervising a nurse prescriber. Dr Jim Kennedy, who is also prescribing spokesman for the Royal College of General Practitioners, believes that the course for nurses prescribing from the extended formulary has been intense and probably too short, perhaps concentrating too much on technical therapeutic areas and not enough on the wider psychosocial aspects of prescribing. He adds that supervision of pharmacists may be more complicated: they will not be part of the healthcare team in the same way as a practice nurse, for example, and access to patients and confidential data may be issues that need resolving.
Website: The Pharmaceutical Journal
 

Brooks et al. The supply of antibiotics by NHS walk-in centre nurses using PGDs. Nursing Times 2003; 99(4): 36-39.
Keywords: Patient group directions; antibiotics; walk-in centres.

A clinical audit to assess the supply of antibiotics by nurses using PGDs at an NHS walk-in centre has provided some evidence that nurses are supplying and administering antibiotics safely and judiciously according to local PGDs, although record-keeping may be an issue.

During the sampling period, 72% of the patients who received antibiotics were assessed and supplied with them by a nurse. More than 99% of the drugs administered followed the PGD. Several of the examples of non-compliance with PGDs may have been down to record-keeping.

Of possible concern was the finding that only 63% of the computerised patient records confirmed that the patient did not have an allergy or contraindications to the antibiotics. The study showed that staff were using both paper and computer records and the authors indicate that this practice has since been changed. When a sample of 20 records of both types were combined, only 53% were found to be complete.

Record keeping has been highlighted as an issue in other studies and settings and this audit confirms that there is room for improvement in the completeness of clinical records. The advent of electronic patient records may help this process.

Website: Nursing Times

 

Hales A and Dignam D. Nurse prescribing: lessons from the US. Nursing New Zealand 2002; 8(10): 12-15

This interesting article explores the experience of nurse prescribers in the USA, some of whom have been prescribing for many years, and looks at the lessons for New Zealand nurses who are beginning the process. A survey of 32 advanced practice nurses (APNs) with prescriptive authority invited them to describe the challenges they had faced, and to suggest how, with the benefit of their experience, they would have approached things differently at the start.

The majority had been APNs for many more years than they had been prescribing and felt that after years as expert clinicians they had become novices again. For nearly half the nurses, acquiring relevant pharmacological knowledge and keeping it current was the greatest challenge and they suggested the following strands of baseline knowledge: know how to interpret laboratory results; know the side effects and interactions of medications before patients are with you; have a philosophy of practice based in current research; and stay up to date by attending comprehensive pharmacology courses and seminars. They also reported that there was always more to know about some subjects: changing doses compared with changing to another medication; adding a medication to treat side effects against changing to another medication; drug-drug interactions; and off-label uses of medications. Advice and support from other professionals, particularly doctors, were seen as important in maintaining knowledge and the first year of prescribing was seen as a time when the need for clinical guidance was most intense.

Accounts of difficulties and stresses with supervising or consulting doctors were common, particularly affecting those nurses in states where they have collaborative (semi-dependent) prescriptive, rather than independent, authority. Relationships with pharmacists could also be frustrating although they, too, were seen as a source of information.
The importance of establishing a role as a nurse prescriber, and how to go about it, was also discussed by the respondents, as was how to retain the nursing role when acquiring prescriptive authority. Many stressed that nurse prescribers should be first and foremost nurses, not “mini-doctors”. They needed to use medication effectively while recognizing the value of non-pharmacological nursing skills. The importance of good communication and resisting pressure from patients to prescribe was highlighted.

The following advice was offered as part of the process of becoming an expert prescriber: keep anecdotal notes about what works and what doesn’t; always write out instructions for the patient – the prescription is not enough; use handouts with information about non-pharmacological intervention as well as drug information; make sure that patients is part of the decision-making process – nurses should educate patients; develop policies on your practice (prescribe, offer informed consent, deal with non-compliance) and keep to them – whatever the patient’s emotional state; communication is central and listening is the basis of clinical assessment; and develop a plan to evaluate the response to treatment.
 

Collins G and George K. Development and support of community nurse prescribers. Primary Health Care 2003; 13(2): 36-38

After commenting on the patchy nature of support for nurse prescribers, and possible reasons why some nurses do not prescribe once they are able to, the authors describe how support groups set up in Shropshire helped the transition to prescriber status and ensured that support and education continued. After 12 months, several clear achievements were identified and recommendations for its future course made. The approach demonstrates the value of informal peer support, although not all nurse prescribers accessed the groups.

Website: Nursing Standard
 

Hutton M. Calculations for new prescribers. Nursing Standard 2003; 17(25): 47-52
Keywords: Drug therapy; mathematics; prescribing

The aim of this useful article is to increase the confidence of nurses who are already trained prescribers, or are being trained to prescribe, in the numerical calculations required for safe prescribing. It looks at types of medication errors and how to avoid them, and then examines basic drug calculations, including working out the costs of different formulations.

Website: Nursing Standard
 

Caulfield H. Nurse prescribing. Legal issues. Practice Nurse 2003; 25(4):48

This short article sets out to look at the legal limits of nurse prescribing, but only considers PGDs and DN/HV formulary prescribers.
 

Gibson F et al. Nurse prescribing: children’s nurses’ views. Paediatric Nursing 2003; 15(1): 20-25
Keywords: children’s nursing; prescribing; nursing roles

The motivation to expand nursing roles to include prescribing stems from a desire to improve the care given to children and their families, concludes this account of a survey of the views of children’s nurses about nurse prescribing.

A telephone and e-mail survey of clinical nurse specialists (CNS), ward sisters and nurse practice educators (WS/NPE) in the Great Ormond Street Hospital for Children NHS Trust was conducted in 2000 to determine the potential for nurse prescribing for children in this group. In total, 47 questionnaires were analysed: 31 out of 40 CNS were contacted by telephone, and an e-mail survey of 60 WS/NPE resulted in 16 responses.

Of the CNS, most said that they did initiate or make changes to a child’s drugs, fluids or medical devices. They used various methods for this: advising and suggesting drugs to doctors; getting the prescription signed by a doctors after the drugs have been provided (often in conjunction with advising and making suggestions); advising parents on action to be taken, with or without informing doctors; giving drugs and products not prescribed (this approach was never used in isolation); using protocols and guidelines to make changes (the only WS/NPE to describe making changes used this approach).

In total, 29 of those surveyed said they would be interested in becoming a nurse prescriber. They all said they would only want to prescribe drugs and products routinely used in their area, including: anti-emetics, sedatives, IV antibiotics, insulin, laxatives, urokinase, dressings, and local anaesthetics for use before cannulation.

Most of the advantages referred to were related to patient care: quicker, more effective discharge, ability to advise families about appropriate treatment, less time wasted in emergencies and improved continuity of care; ability to give immediate care; and less disruption for the family. Other advantages mentioned were: better use of the skills and knowledge of the team; increased confidence when on-call; increased responsibility; smooth running of nurse-led clinics; and getting the prescription correct first time round. Some possible disadvantages included: lack of support from doctors; perception that nurses would be taking on doctors’ roles; and reducing families’ contact with their GP.
The majority of the CNS were prescribing by proxy and although there were protocols and guidelines in place, there were still instances were CNS were administering drugs that were not prescribed. Most, however, were advising doctors on what to prescribe.

Many respondents highlighted the need for clinical experience in relation to prescribing and the CNS often considered that their role and years of experience in their specialty had provided them with the skills and authority to expand their role to include prescribing. All recognized that training and education were required.

The authors point out that although the NPEF contains a long list of medicines, there are few, if any, that are likely to be relevant for children’s nurses.

The article also examines the history of nurse prescribing and current developments at national level.

Website: Nursing Standard
 

Johnson ZK et al. Nurse prescribing in glaucoma. Eye 2003; 17(1): 47-52
Keywords: Glaucoma; nurse prescribing; latanopost; timolol

Nurses could usefully and safely prescribe first-line treatments for glaucoma, according to the conclusions of this study of a nurse-led glaucoma assessment clinic.

The clinic was started at a hospital in Newcastle upon Tyne so that newly referred patients could be seen rapidly, treatment initiated, and the most urgent given early appointments at the consultants’ clinic. Nurses prescribed timolol or latanoprost according to a written protocol, with a member of the medical staff checking the decision against the protocol before prescribing as this was a pilot scheme. Patients started on treatment had a review clinic appointment within one month. Patients diagnosed as normal pressure glaucoma were not considered for nurse treatment but given early medical review.

An audit over defined periods involved 169 patients, of whom 46 had treatment initiated at the clinic: 31 on timolol, 14 on latanoprost and one on brimonidine (in this case, the protocol was over-ruled by the doctor). Four had treatment stopped at the review clinic to reassess diagnosis. Five timolol patients had latanoprost added at the review clinic because of inadequate control and eight were switched to latanoprost (four because of side effects, four because of poor control). None of the latanoprost patients had their treatment altered.

About two-thirds of the patients identified as needing treatment at the consultants’ clinic had been started on it at the nurse assessment clinic, and no patients requiring urgent treatment had been missed. The authors stress that the protocol needs to be tight and strictly followed and that the criteria for identifying visual field loss need to be improved.
The authors argue that glaucoma has a number of features that make it suitable for nurse prescribing by trained ophthalmic nurses, particularly with the new prostaglandins. They suggest that it is more efficient to initiate treatment in a newly diagnosed patient at the assessment clinic, lowering intraocular pressure as quickly as possible, and allowing early modifications to treatment at the follow-up consultants’ clinic. Nurse prescribing should not be used to initiate early treatment for borderline cases of glaucoma or ocular hypertensives.
 

Pearce L. A prescription for change. Nursing Standard 2003; 17 (26): 14-15

Despite the gathering momentum of nurse prescribing, and the resources being made available, it looks like the government’s targets for numbers of nurse prescribers are unlikely to be met, according to this article.

The author quotes a target of 50,000 nurse prescribers by 2004 and says that the Nursing and Midwifery Council (NMC) quoted 28,744 nurses as having recorded their prescribing qualification on the register by April 2002. The overwhelming majority of these were district nurse/health visitor prescribers. She says that 600 nurses are able to prescribe from the extended formulary.

Matt Griffiths, senior lecturer in nurse prescribing at Homerton College, Cambridge, is quoted as saying that prescribing "is one of the biggest changes for decades” and that its impact on the profession cannot be overestimated. One of the benefits he suggests is improving concordance, given estimates that up to half of all prescription drugs are not taken.
The article also looks at other views on nurse prescribing and at how it is being received by doctors.
 

Morrison-Griffiths S. et al. Reporting of adverse drug reactions by nurses. The Lancet 2003; 361: 1347-1348

Nurses can play a valuable part in enhancing pharmacovigilance, according to the conclusion of this study of adverse drug reaction reporting by nurses.

A programme similar to the Yellow Card Scheme was used by the investigators to assess the appropriateness, completeness and causality of 177 nurse reports by community and hospital nurses who had received an information pack and training lasting one hour. In the study period, 137 of the 177 nurse reports (77%) were judged appropriate compared with 676 of 984 (69%) of doctors’ reports used for comparison. Compared with doctors, the proportion of nurses making reports, and the quality of the reporting, were similar.

The authors conclude that the extension of prescribing responsibilities by nurses should be accompanied by an ability, and encouragement, to report adverse drug reactions after training.

Website: The Lancet
 

Caulfield H. The prescription: legal and professional requirements. Practice Nurse 2003; 25(6): 24

This short article looks at the requirements a prescription must meet to comply with the relevant legislation and with the regulatory principles set out by the Nursing and Midwifery Council.
 

Hartley J. Nurse prescribing – the big picture. Nursing Times 2003; 99(14): 23-25

After reviewing the history of nurse prescribing, and looking at its different forms, the author investigates how the training and take-up is proceeding. Nurses’ views vary, with one nurse who runs a minor injuries clinic in a GP’s surgery very enthusiastic about the role prescribing plays in her practice, whereas other nurses see the NPEF as too limited and supplementary prescribing as inappropriate for their practice.

The author reports that the Chief Nursing Officer has proposed to the Committee on the Safety of Medicines that nurses should be able to prescribe emergency asthma medications, menopause treatments, implantable contraceptives and ‘off-label’ drugs. If nurse prescribing is to take off, however, the Department of Health must be convinced that nurses can diagnose medical conditions outside the four areas of minor injuries, minor ailments, health promotion and palliative care.

Website: Nursing Times
 

Hurley G. Enhancing partnership in prescribing. Practice Nurse 2003; 25(7): 21-25

This article looks at how collaboration can help promote safe and effective prescribing and reduce concerns over quality.
 

Axon S. Is pharmacist prescribing our golden future – or is it a blind alley? The Pharmaceutical Journal 2003; 270 (7245): 544

The author argues that supplementary prescribing, which will require a lot of training and revalidation, probably for little reward and limited patient benefit, should be contrasted with a generic prescribing role within the NHS. This would not require additional training, would relieve pressure on GPs and provide a service that was convenient to the public.

There has been a swing from independent prescribing in the community by pharmacists towards a supplementary role in hospitals or practices. The profession initially pressed for a counter prescribing role but this seems to have been quietly dropped. Given the costs associated with training for supplementary prescribing, it is unlikely that it is going to draw in pharmacists from the community sector, despite exhortations that their skills are under-used.

The author also points out that despite their lengthy education and training, the implication of the proposals is that pharmacists, unlike nurses prescribing from the extended formulary, cannot be trusted to recognise the limits of their expertise in generic fields where they have always counter-prescribed.

Practical difficulties, for example what happens in the absence of the accredited supplementary prescriber, and how the Royal Pharmaceutical Society will monitor continuing professional development, are also raised.

Both approaches to prescribing responsibilities could be pursued, as they are being for nurses, allowing the government to realise its stated intention of making better use of pharmacists’ skills across all sectors.
 

Courtenay M and Griffiths M. Primary Health Care 2003; 13(3): 24-25

The authors examine how supplementary prescribing will work, what the role of the independent and supplementary prescribers will be, what the clinical management plan should contain, and what drugs can be prescribed. They go on to look at issues of competence and training, before discussing the possible impact of supplementary prescribing in primary care and its benefits in terms of quicker and easier access to medicines and more efficient use of professionals’ skills and time.

The independent prescriber and supplementary prescriber will have to confer over the clinical management plan and it is possible that this could reduce drug errors, and perhaps help resolve conflicts over prescribing decisions, for example when there is pressure from patients or pharmaceutical companies. The strong emphasis on concordance, with the patient needing to give consent for the partnership to take effect, may help reduce sub-optimal use of medicines and increase the recognition of non-pharmacological nursing skills.

There are also implications for pre-registration education and continuing professional development, with increased requirements for support, knowledge and resources.

Website: Primary Healthcare