VOL: 97, ISSUE: 24, PAGE NO: 40
Jo Skinner, MA, RGN, RM, CPT, PGCEA, DNCert, is principal lecturer and programme director in primary health care, University of North London
Yvonne Savage, BSc, RGN, DipN, DN, is senior lecturer and programme director, primary health care, University of North London
There are seven principles of good nurse prescribing (Box 1). In the first part of our series (June 7, p38), we covered the first three principles. This article discusses the remaining four principles in relation to good practice.
4. Negotiate a contract and achieve concordance with the patient
The implementation and extension of nurse prescribing will demand changes in nursing culture as power shifts from the traditional medical model.
Relationships with GPs, pharmacists, patients, teams, managers and other professional colleagues in both community and acute care settings will change as people understand nurses’ new roles. Confidence and trust need to develop for the benefits of nurse prescribing to be maximised.
Patients will require more information and will need to be more active in making decisions about their own health, including giving consent to treatments. This may require a considerable culture shift for some patients as well as staff.
Prescribers will need to acknowledge that not all patients want this level of autonomy. The nature of the nurse/patient relationship is likely to change, with the responsibility more clearly on the prescriber to give information, support patients and achieve and monitor concordance.
Concordance includes consent, but more importantly it is about the way in which patients are encouraged to engage in their care. This should not be seen as an excuse for prescribers to shift responsibility unfairly to patients - accountability can never be delegated.
Effective working with GPs is important for successful implementation of nurse prescribing. Prescribers need to be skilled in negotiating with GPs, and need to involve their managers where such negotiations are unsuccessful.
Nursing managers also need to be closely involved in supporting - and challenging where necessary - the emerging models of nurse prescribing practice within the clinical governance framework.
Some trust policies focus on the accountability of the prescribing nurse, rather than the resources, development opportunities and support mechanisms that are in place to facilitate best practice. This is an issue that the new primary care trusts may address.
5. Review the patient regularly
Patient review is very important to secure the best patient outcome and safeguard nurses’ accountability.
Thoughtful review requires systematic analysis of all aspects of the care episode, not just prescribed items. Any member of the care team (including the patient and carers) may supply review data regarding the effectiveness of prescriptions. Review decisions should be clearly documented by the prescriber even where no changes occur.
The frequency of reviews needs to be determined on an individual basis. Where a local review policy exists, it will need to be re-examined in the light of best practice. It is likely that reviews will be more frequent depending on what is prescribed, until confidence has been built up.
Given that team members are frequently involved in review, prescribers will need to consider which patient reviews can be delegated, while retaining overall accountability.
It may not be efficient to delegate if the prescriber has to visit to prescribe something else. Reviews will be considered carefully as part of ongoing audit and clinical governance cycles.
6. Keep accurate and up-to-date records
Accurate records are a prerequisite for demonstrating accountability and quality (UKCC, 1998). A number of skills need to be developed to match the demands of modern practice (Box 2).
Prescribers need access to the best technology available for data collection, storage, retrieval and analysis. Internet access is essential for up-to-date material to assist evidence-based practice. The development of IT skills needs to be supported.
E-mail allows prescribers to communicate with colleagues efficiently, although they must be mindful of confidentiality. Electronic prescriptions could soon be available to nurse prescribers.
The advantage of text-based communications is that errors due to handwriting problems are eliminated. However, nurse prescribers need to develop their writing skills, as even the most competent nurse can undermine good practice through poor written work. Clear, unambiguous writing is required to articulate decisions, and nurses need to be able to compile reports based on their prescribing activities.
7. Reflect on your prescribing
Reflection is essential for best practice in prescribing. Many opportunities are built into existing structures - for example, clinical supervision and audit. Managers can help by providing time for formal reflection and resources such as regular PACT data, relevant reports and needs analyses.
Nurse prescribers need to consider their own particular development needs, which may be dealt with via PREP requirements and/or personal development plans. The way clinical supervision is provided and the support mechanisms available also need to be considered within an overall clinical governance strategy.
Writing your first prescription should not be a daunting experience once you are fully confident about your decisions and subsequent accountability.
It takes time to develop confidence and expertise in any new role - and nurse prescribing is no exception. An open culture in relation to prescribing will ensure that high standards develop and unnecessary bureaucracy does not stifle practice.
Prescribing will change the way patients and colleagues in the primary health care team view community nursing practice. It represents a significant power shift from medicine to nursing.
It has been claimed that becoming a nurse prescriber is a natural extension of the community nurse practitioner’s role, which is about improving the quality of care to patients. However, the way in which nurse prescribing is implemented will vary considerably between practitioners depending on their caseloads and the context in which they practise.
It could be argued that prescribing is more about changing perceptions than about a major change in working arrangements. It is essential that nurse prescribers get it right, especially in light of the expected expansion of the Nurse Prescribers’ Formulary and the extension of prescribing rights to others (Department of Health, 1999).
- The Association for Nurse Prescribing is open to all nurse prescribers and provides a forum for discussing prescribing beyond the limits of employing trusts or authorities, tel: 020 7874 0341.
- The website www.nurse-prescriber.co.uk has information on all aspects of nurse prescribing.