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Prescribing for community nurses

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VOL: 97, ISSUE: 28, PAGE NO: 38

Pam Campbell, MSc, RHV, RM, SRN, is senior lecturer in community nursing and module leader for nurse prescribing at Staffordshire University; Guy Collins, BSc, DipN, RN, is a specialist practitioner (district nursing), senior lecturer in community nursing and module tutor for nurse prescribing at Staffordshire University

Nurse prescribing is one of the most positive developments in the profession for many years, with pilot studies consistently showing significant advantages for both patients and professionals (Winstanley, 1998).

 

Nurse prescribing is one of the most positive developments in the profession for many years, with pilot studies consistently showing significant advantages for both patients and professionals (Winstanley, 1998).

 

 

Last month the government announced that nurses of all disciplines will soon be able to prescribe more than 200 prescription-only medicines for 50 conditions as part of a radical expansion of their prescribing powers (Godfrey, 2001). It has also set aside £10m to train 10,000 nurse prescribers by 2004 (O’Dowd, 2001).

 

 

But those who are qualified to take on this role do not always welcome it. In the wake of the government’s latest announcements on the issue (Godfrey, 2001; O’Dowd, 2001), which were made in response to the consultation document on nurse prescribing (Department of Health, 2000), the reasons for their reluctance need to be considered.

 

 

The pace of change
The initial progress of nurse prescribing was notoriously slow - recommendations for some form of prescribing were first proposed in the Cumberlege report (Department of Health and Social Security, 1986). Legal technicalities, funding issues and the medical profession’s reluctance to relinquish sole prescribing rights all had to be overcome before nurse prescribing could be rolled out nationally in 1999.

 

 

However, subsequent progress is accelerating. The last Crown report (Department of Health, 1999) suggested the further extension of prescribing rights to groups such as pharmacists, physiotherapists and chiropodists. Nurses working in a range of specialist areas of practice have also been identified as future prescribers.

 

 

The government’s allocation of funding in 1999 to support nurse prescribing education for district nurses and health visitors was of limited availability until March 2001 (NHS Executive, 1998). This tight timescale meant universities had to accommodate large numbers of students and created difficulties for community trusts, which had to release a high percentage of their workforce for training within a limited period.

 

 

This resulted in individual students having little or no choice about when they went on prescribing courses. Many therefore saw themselves as conscripts, which affected their attitudes to the educational experience.

 

 

Some community trusts provided protected study time for prescribing students, but not all employers could do this because of a lack of cover. As a result, most students were expected to complete the open-learning component of the course in their own time. Many felt that as prescribing was compulsory they should have been given time during working hours to complete the open-learning pack (ENB, 1998).

 

 

The large number of nurses attending courses often resulted in staff shortages, adding to stress in the workplace. Future developments in nurse prescribing therefore need to be rolled out according to a more logical timescale.

 

 

Nurses who are already overstretched may be required to take on the additional role of prescribing in the near future. Although this will save them time in the long run as they will no longer have to ask doctors for prescriptions, acquiring the requisite knowledge and skills will also make considerable demands on their time.

 

 

Prescribing - a choice or a requirement?
Despite a directive that nurse prescribing education should be optional (NHS Executive, 1998), many employers have altered job descriptions to include it. This has led to ambiguity in the future role, responsibilities and grading of a community staff nurse who does not have a prescribing qualification.

 

 

Negativity towards nurse prescribing was often encountered during the taught components of prescribing courses. This is hardly surprising in view of the uncertainty surrounding nurses who failed or refused to go on a course.

 

 

The ENB specified that nurse prescribing education was to be pitched at level three (degree level) to ensure academic credibility and signify a reassuring depth of knowledge to patients, the public and other health professionals.

 

 

Those included in the initial roll out were district nurses or health visitors with a wide diversity of clinical experience and academic achievements. Although their professional competence was assured, unlike most recently qualified staff, who usually have a diploma or degree, their academic qualifications varied. This caused frustration among academics who feared that standards were being lowered to accommodate a significant proportion of students who were not prepared for level-three study.

 

 

To make up the desired numbers of nurse prescribers, some students had to be nurtured throughout the course. Such education contradicts the profession’s philosophy of personal responsibility for professional development.

 

 

So will prescribing be an essential requirement for specialist nurses or an option open to those with their own plans for professional development?

 

 

Changing roles
Until the latest government announcements (Godfrey, 2001; O’Dowd, 2001), nurse prescribing was seen as a form of substitute prescribing and formalised a practice that has existed for many years: the community nurse sees a client, assesses his or her needs and approaches the GP with a prescription request. This was unfair on GPs, who effectively rubber-stamp a request they have not had the time or expertise, for example in the area of wound care, to fully assess.

 

 

Now that nurses are able to sign their own prescriptions, they take full responsibility for the use of a medicine or appliance and must be confident in their diagnosis of the patient’s problem.

 

 

Confidence in diagnostic abilities can be difficult for nurses, even extremely skilled and experienced ones. This may be a result of the nursing profession underrating its own capabilities and the medical profession’s dominance in terms of diagnosis.

 

 

Nurse prescribing relies on an understanding of The Scope of Professional Practice (UKCC, 1992), which empowers nurses to recognise the limits of their knowledge and to work within them. They can no longer hide behind the misguided opinion that ‘the doctor always knows best’.

 

 

Nurses will not prescribe when they are unsure about a diagnosis. But when they are sure, they need to demonstrate the courage of their convictions by initiating treatment. Failure to do so could be described as negligence.

 

 

Encouraging nurses to adopt this attitude is not always easy. While confidence in their clinical abilities is being recognised by giving them the power to prescribe, it is disturbing that barriers are still put in place to slow that process.

 

 

One such obstacle is the proviso in the Nurse Prescriber’s Formulary (British Medical Association et al, 1999) that nurses should not prescribe laxatives for a child without discussing the case with a GP.

 

 

The philosophy underlying this is that the GP holds the reigns of authority concerning prescriptive decisions. But nurses work within their own scope of practice, so if they have the necessary skills to prescribe laxatives for a child they should be allowed to proceed.

 

 

The expansion of the Nurse Prescribers’ Formulary must be underpinned by a fundamental belief in nurses’ knowledge and skills.

 

 

Facilitating nurse prescribing
Current practice for nurse prescribers involves completing a handwritten prescription and recording the details in the patient’s notes. This may be duplicated in other nursing records and in the GP’s records. This takes time, both in terms of paperwork and in accessing the records.

 

 

If a nurse prescriber is attached to more than one practice, this waste of resources is compounded. It is easier for a nurse to ask a GP to authorise a prescription, removing the responsibility of writing the prescription and replicated the records.

 

 

The benefit of not completing the associated paperwork by asking surgeries to produce a prescription is apparent but raises the risk of nurses losing confidence as they become unfamiliar with the process of prescribing.

 

 

The current formulary is limited. Yet anecdotal evidence suggests some GPs are imposing further restrictions on the preparations nurses can prescribe.

 

 

Agreement on practice-based formularies should be encouraged to standardise treatment, but this will require the input by all members of the primary care team. Nurse prescribers should not passively accept what GPs impose on them without consultation.

 

 

When the number of nurse prescribers begins to increase, it is likely that the formulary will also expand significantly. Restricted formularies may be created by employers to encourage optimal evidence-based and cost-effective practice. But it is essential that nurses are then recognised as autonomous prescribers and have a legitimate say in the composition of any formularies relevant to their area of practice.

 

 

Conclusion
The ability to prescribe is further recognition of nurses’ autonomy, diversity of skills and clinical expertise. The anticipated increase in the number of nurse prescribers to 10,000 by 2004 (O’Dowd, 2001) should therefore be seen as a boost to the profession. The initial roll out of nurse prescribing for district nurses and health visitors revealed some teething troubles that need to be acknowledged and addressed before nurse prescribing develops further.

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