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Education and nurse prescribing

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VOL: 98, ISSUE: 09, PAGE NO: 53

Molly Courtenay, PhD, MSc, CertEd, RNT, RGN, is senior lecturer, Buckinghamshire Chiltern University College, Chalfont St Giles;Michele Butler, MMedSci, BSc, RGN, RNT, Cert.Ed (FE), is senior lecturer in clinical science, School of Biological and Molecular Science, Oxford Brookes University

In 1986, recommendations were made for nurses to take on the role of prescribing. Neighbourhood Nursing: A Focus for Care (Department of Health and Social Security, 1986) examined the care given to clients in their homes by district nurses and health visitors. It was identified that some very complicated procedures had arisen around prescribing in the community and that nurses were wasting their time requesting prescriptions from the GP for such items as wound dressings and ointments. The report suggested that patient care could be improved, and resources used more effectively, if community nurses were able to prescribe, as part of their everyday nursing practice, from a limited list of items and simple agents agreed by the DHSS.

 

In 1986, recommendations were made for nurses to take on the role of prescribing. Neighbourhood Nursing: A Focus for Care (Department of Health and Social Security, 1986) examined the care given to clients in their homes by district nurses and health visitors. It was identified that some very complicated procedures had arisen around prescribing in the community and that nurses were wasting their time requesting prescriptions from the GP for such items as wound dressings and ointments. The report suggested that patient care could be improved, and resources used more effectively, if community nurses were able to prescribe, as part of their everyday nursing practice, from a limited list of items and simple agents agreed by the DHSS.

 

 

During 1989 a report was published which made a number of recommendations involving the categories of items for which nurses might prescribe, together with the circumstances under which they might be prescribed (Department of Health, 1989). The report suggested that a number of benefits would occur as a result of nurses adopting the role of prescriber. As well as improved patient care, this included better use of both patients’ and nurses’ time and improved communication between team members.

 

 

During 1992, the primary legislation permitting nurses to prescribe a limited range of drugs was passed - the Medicinal Products: Prescribing by Nurses Act. The necessary amendments were made to this in 1994 and a revised list of products available to the nurse prescriber was published in the Nurse Prescribers’ Formulary (NPF).

 

 

In 1994, eight demonstration sites for nurse prescribing were set up in England. Evaluation of these pilot schemes was positive, and the funding for full national implementation of nurse prescribing was promised by former health secretary Frank Dobson at an RCN conference in April 1998. By the spring of 2001, 20,000 district nurses and health visitors were qualified prescribers. Additionally, postregistration programmes for DNs and HVs included the necessary educational component qualifying nurses to prescribe.

 

 

In 1999 it was recommended that prescribing authority should be extended to other groups of professionals with training and expertise in specialised areas (Department of Health, 1999). During 2001 support was given by the government for this extension (Department of Health, 2001), and funding was made available for other first-level nurses to undergo the necessary training to enable them to prescribe from an extended formulary. This formulary includes the following:

 

 

- All general sales list (GSL) items - those that can be sold to the public without the supervision of a pharmacist;

 

 

- All pharmacy (P) medicines - those products sold under the supervision of a pharmacist;

 

 

- A number of specified prescription-only medicines (POMs), enabling nurses to prescribe in four areas - minor ailments, minor injuries, health promotion and palliative care.

 

 

Education and training
Education and training for extended nurse prescribing has started in January 2002. Programmes are at degree level, involve 25 taught days, additional self-directed learning and learning in practice with a prescribing mentor (a doctor) over a three-month period.

 

 

Compared to the ‘older’ training, which involved an open learning pack and a 15-hour taught component, this is a substantial increase in both the theoretical and practice components. However, it is important to remember the size of the ‘new’ formulary. Although POMs may be limited, the number (over 130) far exceeds those listed on the ‘old’ formulary (12). In addition to this, prescribers have access to all GSL and P preparations. Therefore, it is important that education programmes are sufficiently robust to ensure safe and effective prescribing.

 

 

It has been highlighted by studies evaluating nurse prescribing that areas in which nurses require further knowledge are pharmacology and choice of preparation to be prescribed (Blenkinsopp et al, 1998). The extension of nurse prescribing has meant that there is an increased need for this knowledge. Nurse prescribers are accountable both legally and professionally. Therefore, it is vital that they have a clear understanding of each of the products listed in the extended formulary and are able to provide a rationale for what is prescribed, when over-the-counter products are recommended and when a decision is made not to prescribe or recommend a product (ENB, 1998).

 

 

This knowledge must also be assessed in the context of the following:

 

 

- The patient’s circumstances, including current medication;

 

 

- The patient’s past medical history;

 

 

- The patient’s current and anticipated health status;

 

 

- A thorough knowledge of the item to be prescribed - its therapeutic action, side-effects, dosage and interaction;

 

 

- A thorough knowledge of the alternatives to prescribing;

 

 

- Frequency of use in a variety of circumstances (ENB, 1998).

 

 

Furthermore, a very relevant issue for the nurse prescriber, introduced by the Code of Professional Conduct and the allied Scope of Professional Practice is the notion of nurse decision-making and delegation. That is, nurses are not only responsible for the care they provide but also for the care given by others as a result of a nursing decision. Someone other than the nurse - for example, a health care assistant - may administer items prescribed by the nurse.

 

 

Pharmacokinetics and pharmacodynamics
It is essential that nurses have a thorough knowledge and understanding of pharmacology in relation to each of the products in the extended NPF. This includes pharmacokinetics and pharmacodynamics.

 

 

Pharmacokinetics involves the changes in serum concentration of a drug in the body over time. Absorption, distribution, metabolism and excretion of the drug bring this about. The last two processes also account for elimination of the drug from the body. Pharmacodynamics is the term used to describe what a drug does to the body, including both therapeutic and adverse effects. For nurses to develop their knowledge of these subjects it is essential that they also have a sound understanding of related anatomy, physiology and disease processes. This knowledge will enable them to inform the patient of such issues as:

 

 

- What to expect when prescribing a product;

 

 

- How to administer the product;

 

 

- The duration of time taken in which to see an improvement;

 

 

- The effectiveness of the product;

 

 

- Any precautions the patient should take;

 

 

- The possible likelihood of side-effects, allowing the probable cause to be recognised (a note must be made in the patient’s records following their occurrence)(ENB, 1998).

 

 

Pharmacodynamics and pharmacokinetics in practice
The following example illustrates the importance of monitoring the actions of drugs and detecting their side-effects and interactions. When nurses prescribe oral analgesics - for example, aspirin - they need to be aware of the possible side-effects and drug interactions of this product. Side-effects of aspirin include gastric irritation and bleeding, tinnitus, anticoagulation, hypersensitivity, liver and kidney impairment, Reyes syndrome and foetal defects in pregnant women. Aspirin interacts with a number of drugs including anticoagulants.

 

 

To fully appreciate these effects and interactions an understanding of the action of aspirin at a cellular level is a necessary prerequisite. This knowledge will enable nurses to identify those client groups in which aspirin should be avoided. These would include patients with a history of gastric problems; elderly people, as this group suffer from a greater degree from this side-effect; people with asthma, as they are more likely to suffer from hypersensitivity; clients with renal and liver impairment; pregnant women, breast-feeding mothers, and children under 12. It should also be used with caution in clients receiving a low daily dose for the prophylaxis of cerebral vascular disease or myocardial infarction.

 

 

Similarly, an awareness of the abdominal cramping associated with stimulant laxatives would enable nurses to warn the patient of this particularly unpleasant side-effect and be aware of its possible occurrence.

 

 

A knowledge of anatomy, physiology and disease processes is essential to understand the routes of administration of medicines and how medicines are absorbed. For example, when prescribing topically administered medications to elderly people it is vital that nurses appreciate why the absorption rate of these medications decreases in this client group. To begin to develop an understanding of this issue, they need to be aware of the physiological changes that occur to the skin as people age, such as decreased hydration, increased keratinisation and decreased blood perfusion.

 

 

To fully understand orally administered medication, knowledge of the gastrointestinal tract is crucial. Factors that effect absorption, such as pH of the absorption environment and motility of the gastrointestinal tract, can then be fully appreciated.

 

 

Conclusion
It is clear that, if nurse prescribers are to prescribe safely and effectively and be accountable for their prescribing decisions, there is a need for them to develop and maintain their knowledge of pharmacology, anatomy, physiology and disease processes. This series of articles will examine the pharmacology of some of the POMs listed in the extended NPF.

 

 

- This article is based on a book by Courtenay, M. and Butler, M. Essential Nurse Prescribing, to be published in April 2002 by Greenwich Medical Media, London

 

 

KEY READING
Blenkinsopp, A. et al (1998)
Nurse Prescribing Evaluation (1): The Initial Training Programme and Implementation. Keele: Keele University Department of Medicines Management.

 

 

Department of Health (2001)Consultation on Proposals to Extend Nurse Prescribing. London: DoH.

 

 

ENB (1998)Nurse Prescribing Open Learning Pack. Milton Keynes: Learning Materials Design.

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