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The impact of prescribing in wound care on nurses and patients

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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.

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.



The implementation of patient group directions has also enabled other groups of nurses directly involved in wound care, for example in nurse-led minor injury units, to prescribe without first consulting a medical practitioner.



Background to nurse prescribing
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.



An analysis estimated a cost saving of around £12.5 million a year in nurses’ and doctors’ time, balanced against the £8 million necessary for training (DoH and Touche Ross, 1991). It has been suggested that the cost of training was one reason for the Government’s failure to make any further real commitment to nurse prescribing (Jones and Gough, 1997).



However, when the Royal College of Nursing persuaded Roger Sims MP to introduce a private members’ bill, it received widespread Government support. As a result, the Medicinal Products: Prescription by Nurses Act was passed in 1992, giving nurses the power to prescribe (Jones, 1999).



Eight pilot sites for nurse prescribing were chosen and the project began on October 4,1994. The initial aims were to examine nurse prescribing and assess its benefits and workability in clinical practice along with the cost implications (Winstanley, 1999).



Early evaluations indicated that, in general, nurses and GPs felt that nurse prescribing worked well (Luker et al, 1997a). Closer working relationships with other primary care providers, for example pharmacists, were established (Winstanley, 1999). Patients found that nurse prescribing provided increased satisfaction, quicker access to treatments, improved health information and a closer relationship with the prescribing nurse (Luker et al, 1997b; 1998; Brooks et al, 2001a; 2001b).



In the past, certain groups of nurses, such as practice nurses, were acting as ‘unofficial’ Prescribers under group protocols (Jones, 1999). Much of this ‘prescribing’ was undertaken without any prior monitoring or training leading to concerns regarding competency and patient safety (Jones and Gough, 1997). Crown made further recommendations for future practice under group protocols (DoH, 1999). Legislation enabling patient group directions, as protocols came to be known, was subsequently passed in 2000 (DoH, 2000).



Group directives have since been successfully implemented in areas such as immunisation programmes, minor injuries units and family planning clinics (Mayes, 1999). They can also be applied to areas of tissue viability in order to prescribe wound-care products, provided the product, clinical circumstances and prescribing clinician meet the specified criteria (Gooch, 2000).



Nurse prescribing in wound care
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).



The need for accurate wound assessment and continued evaluation by prescribers has been recognised (Courtenay and Butler, 1999; Bentley, 2001; Bowskill, 2001). It is debatable whether such a brief training programme fulfils the needs of all practitioners, or educates them to the standard required to appropriately manage a variety of wounds.



Tissue viability nurses were initially excluded from prescribing training. One reason for this may be the only recent emergence of tissue viability nurses as specialist practitioners (Hill, 1996) and as nurse consultants in tissue viability. Although some practitioners spend time in clinical practice, those who work at a managerial or organisational level may not have direct patient contact (King, 2000). It was argued that patient care would be enhanced because as tissue viability nurses with clinical responsibilities would have their own caseload and have a greater role in the co-ordination of community leg ulcer clinics (King, 2000).



Implications of prescribing for expert practitioners
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.



Another reason given for the patient preferring to consult a nurse prescriber as opposed to a GP is that they were considered to be experts in some fields, particularly wound care. They were therefore seen to promote wound healing. Such a view is also perpetuated by doctors who often turn to their community or practice nurse for advice on wound management (Luker et al, 1997a; Fellows, 1999).



Again, this has repercussions. If doctors are supposed to be assessing nurses as ‘competent’ to prescribe, what happens when they encounter a patient with, for example, leg ulcers? How is competency to be assessed? It is possible the nurse would be deemed competent simply because he or she was thought to be more knowledgeable than the assessing medical practitioner, which may have implications for the standardisation of prescribing training. Perhaps there is a role here for the tissue viability nurse specialist in assessing the competency of potential prescribers to assess, prescribe and treat in wound management. Box 1 lists the main criticisms of nurse prescribing.



The role of the supplementary prescriber
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.



The consultation document for supplementary prescribing has only just been published (DoH, 2002b). Therefore, further research into the impact of supplementary prescribing and particularly the patients’ view, will need to be undertaken once the service is implemented.



Prescribing issues and concerns in wound care
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).



Nevertheless, it has been demonstrated that nurses’ underlying knowledge of wound management products is often poor (While and Rees, 1993; Turner and Thomas, 1994). Worryingly, nurses do not always access the most appropriate evidence available when selecting wound-management products. Often they turn to colleagues, pharmaceutical representatives or product literature in place of research-based evidence or clinical practice guidelines (Barlow, 1999). They may also lack access to resources at work, such as the Internet, to help them update their knowledge (Otway, 2002).



Choosing an appropriate wound-management product can be further complicated by the fact that new dressings are constantly being developed and marketed (Bale, 1999). This poses the question of what happens when new products supersede the old. How and when will the formulary be updated, and who will decide what is to be included? This will also have implications for the further training of nurse prescribers in the use of newer products. Again, there is a role here for tissue viability nurse specialists in the development and maintenance of educational programmes to provide ongoing support for prescribers. In addition, while nurse prescribers sometimes consider patient comfort when choosing dressings (Barlow, 1999), further research needs to be undertaken to assess the impact of prescribers’ selection of dressings on the patients’ quality of life and the resulting cost/benefit implications.



Many patients felt that the continuity of care they received as a result of nurse prescribing was enhanced (Brooks et al, 2001a; 2001b); this also increased patient confidence (Chapple et al, 2000).



Patient perspectives
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.



Thus, as nurses develop new roles, patients are seen as ‘monitors’ who will turn to litigation when things go wrong (Chapple et al, 2000). It has been suggested that patients’ perceptions of nurse-led services are formed through discussion with other patients, personal experience of the service and preconceived ideas of the nursing/medical role (Chapple et al, 2000). Whether patients are accepting of these nurse-led roles is dependent on a positive personal experience of using the service and ultimately whether their needs were met (Chapple et al, 2000). Therefore, it is important that patients’ views and experiences are considered in an evaluation of nurse prescribing.



The Cumberledge and Crown reports emphasised the benefits of nurse prescribing (Box 2). It is important therefore, to examine how this translates into clinical practice and whether the views of patients are consistent with these predetermined benefits.



Patients’ perspectives
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).



Patients also reported fewer journeys to obtain prescriptions (Luker et al, 1997b) and viewed prescribing as an improved use of the nurses’ time, leaving GPs to deal with more serious complaints (Brooks et al, 2001a; 2001b). This had a knock-on effect on the issue of under reporting. Patients were sometimes reluctant to ‘bother their GP’ with problems that they perceived to be minor or unimportant and seemed more willing to discuss such `minor’ issues with the nurse prescriber (Luker et al, 1998). This was primarily due to the ease with which the nurse was available as opposed to obtaining a GP appointment. However, it was felt that the nurse had more time to explain and discuss issues, and provided better-quality health promotion/information in terms that were easy to understand.



Nurses undertaking prescribing training for the extended formulary are required to spend 12 days developing competency under the supervision of a medical practitioner (DoH, 2001). If patients prefer the nurses’ approach to information-giving, perhaps it is possible for doctors to learn improved communication skills at the same time. Indeed, could nurses’ communication skills be used as a benchmark for doctors? Patients also preferred `the approachability and friendliness’ of the nurse prescriber. Such a nurse-patient relationship is the cornerstone of successful patient care and its importance should not be underestimated. The Crown report (DoH, 1989; Jones, 1999) made specific references to nurse prescribing as a catalyst for improved nurse-patient relationships and it is reassuring to note the evidence presented from these early studies appears to confirm that this is occurring.



Patients also stated the importance of appropriate training for nurse prescribers in order for them to be competent in their role (Luker et al, 1997b, 1998; Brooks et al, 2001 a, 2001b). The DoH has recognised the significance of maintaining competency to prescribe both through initial training and beyond. It is important, therefore, that nurses are seen to be supported through a robust educational programme if patients’ faith in nurses’ abilities is to be maintained. Perhaps the length of prescribing training could be extended further, utilising specialist practitioners such as tissue viability nurses in the education and audit of prescribers, and compulsory update programmes to enable prescribers to re-register.



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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