VOL: 98, ISSUE: 41, PAGE NO: 43
Pat Anderson, freelance journalist
Sponsored by Pfizer
Nurse prescribers need to understand the limitations and advantages of different information sources, and be able to assess the value of the data they read. This is a particular expectation of the National Prescribing Centre’s outline framework of prescribing competences (National Prescribing Centre, 2001). These are not easy tasks, given the plethora of information, therefore nurses need to know how to find their way through the maze and know where the best data are available.
The National Prescribing Centre
The aim of the National Prescribing Centre is to promote high quality, cost-effective prescribing by supporting professionals and managers in the NHS. It provides resources to support the continuing professional development of nurse prescribers, which includes publishing the MeReC Bulletin. Evidence-based bulletins and resource packs can be downloaded from the Centre’s website (www.npc.co.uk), and cover the following areas:
- Signposts for prescribing nurses
- Wound management
- Scabies and threadworms
- Head louse infection
- Urinary incontinence
MeReC Bulletin is a bi-monthly publication (every two months), and is also available on the website. It provides clear and evaluated information on medicines and prescribing-related issues. Its aim is to provide realistic information covering topics particularly relevant to primary care health professionals.
The National Prescribing Centre has also developed an outline competency framework for nurse prescribing designed to help nurse prescribers and their managers assess how well they are carrying out their role and also to identify training and development needs. The Centre’s outline framework of prescribing competences is published in a document entitled Maintaining Competency in Prescribing: An outline framework to help nurse prescribers (also on the website), and is being disseminated to all existing nurse prescribers through their local nurse prescribing leads. Future nurse prescribers will receive their copy during their initial preparation programme.
The framework outlines the competences required of nurse prescribers. They should be able to:
- Understand the advantages and limitations of different information sources
- Use relevant, up-to-date information whether this is verbal, on paper, or from an electronic source
- Critically appraise the validity of information, such as research reports and promotional literature
- Apply information to the clinical context
- Use relevant patient record systems, prescribing and information systems, and decision support tools.
Finding the evidence
While most healthcare professionals endorse the move towards evidence-based care, in practice, keeping ahead of the changes affecting nurse prescribers is not that easy. How, for instance, is it possible to know what constitutes good evidence, and where can it be found?
Good sources of evidence include the British National Formulary (BNF), the Nurse Prescriber’s Formulary, the Drug Tariff, National Prescribing Centre materials, the Department of Health website and evidence-based websites such as Bandolier. Other sources include hospital medicines information services, the Royal Pharmaceutical Society, the National Pharmaceutical Association and the pharmaceutical industry (Wiffen, 2001).
Both the BNF and the National Prescribing Centre are good independent and reliable sources of sound information. More detailed information is available in the summary of product characteristics published in the electronic Medicines Compendium. Drug and Therapeutics Bulletin and the National Prescribing Centre’s MeReC Bulletin, the evidence-based reviews in the Cochrane collection and the University of York’s Effective Healthcare Bulletin are further reliable sources of information. Another useful source is druginfozone.org.uk, a website run by the London region’s medicines information service which has a section dedicated to nurse prescribing to help prescribers keep up-to-date. Box 1 lists some useful sources of information, together with their web sites.
Some recent research into the information sources used by nurse prescribers shows that discipline-specific journals and local formularies are popular. A recent study (Otway, 2002) of the literature sources of nurse prescribers showed that 350 prescribers in a local health authority sought closely-targeted information, and tended to read that specific to their discipline, such as practice nursing, health visiting or district nursing. They were also using the BNF, and some primary care groups had their own wound care formulary, having asked a tissue viability nurse to help them write it.
Material from pharmaceutical representatives
Otway’s research also showed that nurses used other, potentially less reliable, sources of information, in particular that from pharmaceutical representatives, although they did seem to be aware of the potential bias in such material. There is a danger that, as more nurse prescribers are appointed and their workload increases, they will take this easy option of obtaining information instead of taking the time to search independent evidence-based material. Nurse prescribers should always be aware that a drug company’s aim is to promote its products. Moreover, the company may have funded its clinical trials. The key is to remember that the way in which trial results are presented always needs careful assessment, ideally by someone skilled in the art of critical appraisal. This is why information sources such as Drug and Therapeutics Bulletin and MeReC Bulletins are so useful, as they provide independent and objective assessments. Drug company information is not, of course, necessarily bad, but it is important to ask pharmaceutical representatives to give both the pros and cons of a particular drug as they may well emphasise only its positive aspects. A good method is to use the product information in conjunction with the BNF.
Many healthcare professionals have expressed concern over the quality of data found on the internet. It is difficult to find evidence-based sources here and also difficult to know the integrity of the material presented. There are ways of overcoming these deficiencies, however; for example a bibliographic database such as CINAHL or Medline can be used to review peer reviewed material (although only an abstract may be provided); or an online journal such as nurse-prescriber.co.uk, which is specific to the needs of nurse prescribers and is peer reviewed and quality controlled.
Another option is to join newsgroups such as the nurse prescribing newsgroup at www.mailbase.ac.uk, or use the forum at www.nurse-prescriber.co.uk to put questions to others - although it is important to be aware that newsgroups have no quality control.
Pharmacists and GP colleagues
In the face of conflicting information and a lack of time, seeking the advice of other healthcare professionals is another option to consider. Pharmacists, in hospital or the community, are the ideal colleagues, as they have an in-depth knowledge of drugs and their actions and interactions. In addition, medicines information services - listed by region at the back of the BNF - are useful for theoretical queries, while more practical advice can be sought from community pharmacists, primary care groups or primary care trust advisers and community health trust advisers.
In some areas, nurse prescribers have good local support. For example, the Somerset Nurse Prescribing Forum offers quarterly meetings with a peer-led agenda. This ranges from updates on clinical topics with a pharmacist available to offer advice on the spot, to discussion of strategies for dealing with prescribing problems. In South and West Bradford, nurse prescribers and those working to patient group directions can access the local primary care trust’s pharmaceutical adviser and attend a trust-wide forum composed of nurse prescribers, GPs and pharmacists. The forum reviews all patient group directions and prescribing issues, including the expansion of nurse prescribing and the associated training needs and, when it goes ahead, it will cover supplementary prescribing.
Although healthcare colleagues can be a very useful resource, not all nurses enjoy the benefits of accessible pharmaceutical advice or of friendly GP colleagues. Otway’s research (2002) has highlighted a lack of support and networks in many areas. Not all had pharmaceutical advisers and, if they had, they were not necessarily working with nurse prescribers. She concludes that where relationships were good, nurses used the GP for information, but there was a wide variation in how supportive the GP was.
Providing support to nurse prescribers is part of the pharmaceutical adviser’s agenda but at the moment, the demands of reorganisation mean that it is not one of their higher priorities. However, as nurses get more involved in delivering national service frameworks, they are likely to get more support.
Nevertheless, nurses might have to push for extra help if they are to ensure that issues around nurse prescribing are on the agenda at primary care trust level. It is important to remember that nurse prescribing is an important part of the clinical governance agenda.
Next week: Local formularies; An on-line educational website.