VOL: 96, ISSUE: 36, PAGE NO: 19
Brenda King, BSc, SRN, ONC, DNCert, is a tissue viability nurse, Manor Clinic, Community Health Sheffield NHS Trust
Nurse prescribing has been on the agenda since the Cumberlege (1986) and Crown (1989) reports first recommended it. In line with The Scope of Professional Practice (UKCC, 1992), it can only broaden what is already a constantly changing role.
Its implementation, however, has been slow. After the promulgation of the Medicinal Products: Prescription by Nurses etc., Act 1992, the first pilot sites were set up in eight fundholding practices in 1994. They highlighted the many benefits of nurses prescribing, not only from nurses’ perspective but also for GPs and patients, and in May 1998 nurse prescribing was extended nationally.
It will finally address the issue of GPs simply countersigning prescriptions at the nurse’s request. This is common practice in wound care, which has historically been the nurse’s domain. But tissue viability specialists, who are often involved in managing patients on a day-to-day basis, have been excluded from prescribing.
The second Crown report (1998) acknowledges that these nurses, along with others working in specialist areas, should be eligible for the nurse prescribing programme, although no date has been set for their inclusion.
It is significant that the Nurse Prescribers’ Formulary includes wound management products, dressings, skin preparations and cleansing agents, and the ability to prescribe them could have a substantial impact on the role of the tissue viability nurse.
Working in the community
Like other clinical nurse specialists, the community tissue viability nurse’s role has developed rapidly with little clarity or definition (Flanagan, 1998; Glen and Waddington, 1998). The UKCC (1999) has tried to address this issue but there is still confusion, with some operating at a managerial and organisational level (Haste and MacDonald, 1992) while others spend more time in clinical practice.
This diversity of roles, which means that some tissue viability nurses are not directly involved in patient care, could affect the future of nurse prescribing in this group.
I work for a community trust that services a city with a population of more than 500,000. Although developing and providing educational programmes, guidelines, policies and care pathways for the management and prevention of chronic wounds is an important aspect of my role, more than half my time is spent on direct patient contact.
This involves visiting and assessing patients in their homes, GP surgeries or nursing homes, and playing a part in the coordination and management of community leg-ulcer clinics.
Decisions on the management of a wound are taken after a clinical assessment of the patient, during which it often becomes obvious that treatment should begin as soon as possible, particularly if the current regime is detrimental.
The advantages of tissue viability nurses being able to prescribe are obvious: it would prevent delays in obtaining prescriptions, enable treatment to start almost immediately and eliminate the cost of inappropriate prescribing. The benefits of immediate treatment also need to be formally recognised.
Nurse prescribers are required to provide a sound rationale for the treatment decisions they make. This should not be a problem for tissue viability nurses, who should have a thorough knowledge of wound care, be up to date on research and be able to analyse it critically.
Giving tissue viability nurses the right to prescribe would herald an improvement in patient care in the community and lead to greater job satisfaction.
Schools of nursing at several local universities have developed validated training programmes for nurse prescribers. The number of nurses to be trained within a specified period and the total prescribing budget available to them have also been identified.
To date, 115 of the nurses in the trust I work at have been trained and another 135 are due to be trained during the current financial year.
The Crown report (1998) specified who would be eligible for training, using criteria such as specific areas of practice and the possession of certain postregistration qualifications, including a district nursing qualification.
I applied for training, but although I have a district nursing qualification I was refused a place on the programme because the issue of prescribing powers for specialist nurses has not yet been addressed.
The rationale for refusing to train specialists such as tissue viability nurses was that they did not have enough clinical involvement with patients. So if a district nurse asks my advice on a wound management regime, we can visit the patient together but I am not able to prescribe an appropriate product. I can, however, inform the nurse, who will then be able to prescribe it.
Confusion over products
For the past six years the trust’s community wound care guidelines have been an important source of advice on generic wound management products. But primary care groups in the area now have teams working on the development of local formularies for prescribing, including one for wound management products.
The development of the wound management formulary, which will be guided by a city-wide group that includes tissue viability nurses, pharmacists and district nurses, was necessitated by a plethora of new products flooding the market.
The number of similar products available has caused confusion. For example, it has been reported locally that different brands of hydrogels have been used on the same wound at the same time. Different brands of the same product have also been substituted in treatments, wasting valuable resources.
The implications of a directive formulary
The introduction of a directive formulary has implications for nurse prescribers in the trust and reactions to the proposal have been mixed. Some nurses welcome the clear direction a formulary will give because this will help to reduce the pressure put upon them by company sales representatives offering products for trial and seeking feedback. They also realise the potential benefits of a group of professionals reviewing and interpreting the supporting literature and research papers provided by companies.
But some nurses have indicated that they do not want to be told what to prescribe, even though there is scope for them to prescribe products that are not listed.
I have been advised that I can apply for a place on one of this financial year’s training cohorts under the guise of a member of the flexible workforce. But I may not be able to use the qualification until the issue of prescribing powers for specialist nurses has been addressed.
The wound management formulary needs to be finalised, agreed and implemented, and appropriate training programmes set up. Then its effectiveness will have to be evaluated.
The way forward may be through primary care trusts, which could buy wound management products in bulk or from a single supplier. The future, therefore, may involve calling for tenders from companies that can provide a complete supply service, from the provision of a full range of wound care products to the management of storage, stock control and prompt delivery, including a bespoke educational package for each primary care trust.