VOL: 102, ISSUE: 39, PAGE NO: 50
Ann ShuttleworthThe clinical management plan (CMP) was developed to support supplementary prescribing, enabling independent nurse p...
The clinical management plan (CMP) was developed to support supplementary prescribing, enabling independent nurse prescribers with a supplementary prescribing qualification to prescribe medications outside the nursing formulary. But now nurses have access to most of the British National Formulary, do they need the CMP?
Barbara Stuttle, director of primary care and modernisation at Thurrock PCT and chairperson of the Association of Nurse Prescribing, believes the CMP remains useful in some situations. 'There is certainly still a place for the CMP, particularly with patients who have very complex needs because they have multiple conditions,' she says. 'It's also useful when patients are not very stable - sometimes you need the expertise of both a doctor and a nurse, and the CMP is designed to facilitate that.'
Ms Stuttle also points out that the CMP provides a tool for communication between professionals. 'Healthcare is about a partnership between professionals and the CMP facilitates that partnership. If we stop using it we stop communicating effectively.'
However, she adds that nurses could learn from their medical colleagues' documenting practice in order to develop concise CMPs that serve all professionals. 'Doctors tend to stick to more factual information about the patient's condition and medication, but sometimes nurses can make them a bit too wordy', she says.
Mo Beckenham, practice nurse, Kent House Surgery, Longfield, Kent, believes the CMP has a real place in the community. 'It can be especially helpful for community matrons, and I think they may benefit most,' she says. 'They are often out on their own in patients' homes and may be caring for older people with complicated and multiple conditions. The CMP can give boundaries - for some conditions there are so many drugs available, and this is made more complicated by polypharmacy, so it can be really helpful to develop a CMP.'
Ms Beckenham also believes the CMP can help to develop confidence. 'At the moment I don't use CMPs within the scope of my practice, but if I took on a new disease area I would do the necessary training then I would probably use CMPs for a while.'
However, Ms Stuttle points out that prescribing skills are still vital in these situations.
'It shouldn't be seen as a way of learning prescribing skills - even when you are working with a CMP you still need to be able to assess and monitor your patients to ensure what they are being prescribed is right for them,' she says.
Ms Beckenham feels the CMP is an important tool when a number of professionals are involved in a patient's care. 'You may have several nurse prescribers visiting the same patient over a period of time,' she says. We all have particular drugs we tend to use first when a number are available, so the CMP means patients receive coordinated care.'
While nurses have access to most of the BNF there are still restrictions on controlled drugs, so nurses in pain management and palliative care will still need CMPs. The CMP also has a role when prescribing drugs outside the terms of their licence (off licence). Although nurse prescribers can, under certain conditions, prescribe off licence, a CMP can be useful, while they must use always a CMP in prescribing unlicensed drugs (see Box).
Prescribing for children
When testing medications in order to gain a licence, most drug manufacturers restrict their research to adults. As a result, many medications are unlicensed for use with children. The BNF for Children (BMJ Publishing Group et al, 2006) advises on the off-licence prescription of medications, based on consideration of the options available to manage a given condition and the weight of evidence and experience of the unlicensed intervention.
Prescribing for children does not simply involve reducing doses based on the individual child's weight, and nurses need specific competence in this area if they are to prescribe for children - even when treating conditions with which they are familiar. The CMP is potentially a useful way for nurses to develop experience and competence in prescribing for children in general, and in enabling them to provide comprehensive care for individual children.
A vital tool
While the use of the CMP will inevitably decline as nurses develop more prescribing experience, it remains a useful tool in prescribing for some patients and in some situations. However, for some nurses it remains vital to enable them to provide patients with the medication they need.
Unlicensed medications can be prescribed with the doctor and patient's agreement providing:
- No alternative, licensed drug would meet the patient's needs
- The evidence base supports its use for the patient
- The doctor takes responsibility for the prescription
- The patient understands the medication is unlicensed and agrees to its prescription
- The medication and reason for the prescription is documented.