Karen LayFlurrie, RN.
Staff Nurse, Windsor Wing Day Hospital, Hemel Hempstead General Hospital, Hemel Hempstead, Hertfordshire
Wound management is increasingly viewed as the nurse’s domain. Along with the advent of advanced clinical practice and the development of specialist nursing roles, such as that of the tissue viability clinical nurse specialist, extending the role of prescriber to these groups of nurses may bring further benefits to patient care and increase job satisfaction.
In the late 1980s the Department of Health ordered an advisory group, under the direction of Dr June Crown, to explore the implications and issues surrounding nurse prescribing (DoH, 1989; Jones, 1999). The recommendations of the subsequent Crown reports (DoH,1989) were that nurses should have powers to prescribe drugs, dressings and appliances and the ability to vary dosages and timings of drug regimens.
In 2001 independent nurse prescribing was extended to other groups of practitioners, including tissue viability nurses and the Nurse Prescribers’ Formulary was extended (DoH, 2002a). The training programme has been extended from three to 25 study days at level three and 12 days learning in practice. The training is to include consultation, decision-making and referral, clinical pharmacology, evidence-based practice and clinical governance and legal, ethical and accountability issues. It is predicted that competency will be judged through assessment by a supervisory practitioner, the maintenance of a portfolio and a written examination. The Nurse Prescribers’ Formulary contains a variety of wound-management products including hydrocolloids, foams, alginates, desloughing agents and bandages (Courtenay and Butler, 1999).
Why do tissue viability nurses need prescribing rights? In community settings, they may be involved in joint assessments with district nurses who may then take over a patient’s care. In hospitals, apart from areas such as minor injuries, there is little need for them to prescribe, as medical staff are more accessible. It has been suggested that their role should be one of educator, policy-maker and researcher, ensuring that the practice-theory gap is closed and evidence-based care is implemented (Hill, 1996; Gooch, 2000). This would ensure that nurses who already have prescribing rights are supported and educated. They would then not only prescribe wound-management products, but have the necessary skills and knowledge to undertake a holistic assessment of the patient with a wound, identify factors delaying healing and have an appreciation of quality-of-life issues that are already the basis for tissue viability nurse education.
The final Crown report suggested that there should be two levels of prescriber, independent and, in addition, supplementary prescribers (DoH, 1999; Gooch and Bennett, 2000). The main difference between the two is the ability of the independent prescriber to diagnose and prescribe the initial treatment. When a patient is suffering from a chronic condition, such as leg ulcers, it may be possible for them to be diagnosed and prescribed for by an independent prescriber and issued with repeat prescriptions by a supplementary prescriber. Thus continuity of care could be maintained.
District nurses are more frequent prescribers and most commonly prescribe wound-management products (Luker et al, 1997a). With the majority of patients, for example, with leg ulcers being treated by district nurses in their own homes, along with newer advances such as community leg ulcer clinics, it could be suggested that nurse prescribing is a useful attribute (Winstanley, 1999).
While legislation and education can push forward the boundaries of the future nurse’s role, it is ultimately the patients who have to accept such changes in order for them to be successful (Chapple et al, 2000). Through initiatives such as Your Guide to the NHS (DoH, 2002c) and the National Institute of Clinical Excellence, patients are no longer seen as passive receivers of care and are instead encouraged to participate in the decision-making process.
There have been two main studies into patients’ views of nurse prescribing, both of which showed similar findings (Luker et al, 1997b; 1998; Brooks et al, 2001a, 2001b). Patients perceived the biggest benefit to be timeliness of treatment. The nurse could see the patient and issue a prescription on the same day, meaning treatment could start earlier. This had potential benefits in wound management where changes to dressings could be made immediately. This benefit could also be extended to patients newly discharged from hospital (Luker et al, 1997b) particularly on occasions where the service fell short; for example, the patient being discharged from hospital with inappropriate dressings (Winstanley, 1999).
Initial evidence suggests that patients have welcomed nurse prescribing. Nurses are in a unique position to prescribe due to their ability to form close relationships with their patients based on mutual respect, friendliness and approachability (Luker et al, 1998). In some specialist fields, such as tissue viability, where underlying knowledge may be lacking, specialist nurses have an opportunity to influence the support and education of nurse prescribers as well as utilising their own prescribing skills for the benefit of patients.
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