VOL: 97, ISSUE: 23, PAGE NO: 38
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
Your registration has arrived from the UKCC, your blank prescription pad is just waiting to be written on and your patient looks at you expectantly. Everyone says this is a giant leap forward for nurses, but it feels like just one more thing to make you anxious during your already busy day. How are you going to cope with this new responsibility?
To begin with, familiarise yourself with the seven principles of good prescribing (Box 1). But before you begin ticking them off, remember that although they form a useful framework for practice they are limited in terms of broader accountability, including personal, professional and employment issues (Dimond, 2000). There is always a danger that a checklist may encourage a minimalist approach, which could leave nurses vulnerable regarding their wider accountability.
All nurses are accountable for their practice. Put simply, accountability is about making the best decisions and standing by them. And because nurses are accountable whether or not they prescribe, prescribing merely presents another new challenge. Although nurses do not work independently of others and teamwork is important, accountability for writing the prescription itself cannot be shared.
Prescribing has been on the agenda for a long time (Department of Health and Social Services, 1986; Department of Health, 1989), but it is only recently that prescribing training has been extended to all district nurses and health visitors. Practitioners, managers and others face a huge learning curve concerning its implementation.
It is important for nurses to develop into their new accountability safely and confidently. This means improving existing skills and developing new ones. It takes time to develop confidence and expertise in any new role and nurse prescribing is no exception. It is important to have an open, supportive, no-blame culture to enable practitioners to mature into the role and develop good models of prescribing practice.
It is inevitable that long-held customs and practices in the community will be challenged and changed as a result of the new prescribing rights and that many professional issues will need to be addressed. Here we discuss the different aspects of this new nursing role by taking a closer look at the seven principles of good prescribing. Principles four to seven will be covered in next week’s article.
1. Examine the holistic needs of the patient
Nurse prescribing is not an isolated activity but part of the entire care programme. Prescribing should be integrated into the holistic nursing assessment process by incorporating it into the philosophy or preferred theoretical nursing framework. And this is where the potential to change the traditional way of prescribing in primary care lies. Nurses should not use prescribing to short-circuit the assessment process or as a method of terminating an interaction with a patient. They will need to be proactive in their assessments and not wait for patients to draw certain factors to their attention.
For example, as nurses can prescribe analgesics they will need to ensure that any assessment includes an evaluation of the pain a patient may be experiencing. And because the management of leg ulcers requires detailed clinical measures to establish causation before treatment can begin, all nurses prescribing in this area of care should have access to and be proficient in the use of Doppler equipment.
Nurses need to make decisions based on the best available evidence and any decision on whether or not to prescribe should be clearly recorded with the assessment data collected. They also need to be precise about the clinical indicators and tests required as part of data-gathering in relation to prescribing decisions. This should be a considered process and should not be rushed because of time pressures. Nurse prescribers should also not delegate assessments to others, so their workloads may need to be reorganised to accommodate this.
2. Consider the appropriate strategy
This principle focuses on planning the patient’s individual care. However, it is important for prescribing nurses to consider their wider strategic role, for example, how GPs and nurses should work together in the NHS.
Some criticisms of the nurse prescriber’s role are a result of the problem of community nurses being drawn towards a medical approach to health. This challenges the relative autonomy that prescribing promised: are nurses developing their roles or are they taking on tasks that GPs no longer want? Nurse prescribing needs to be clearly represented as developing nursing to meet patients’ needs within the broader nursing strategy.
Although the current formulary is very limited there is still potential for misuse and abuse. Nurse prescribers need to ensure that they are working in accordance with the UKCC code of conduct and agreed local guidelines (UKCC, 1992). This means they must have access to appropriate and regular professional development and quality data.
Apart from good evaluation skills, nurse prescribers need to be assertive about their prescribing decisions, making the best interests of the individual patient their priority. But even though they have the authority to make prescribing decisions, this may be frustrated by a lack of autonomy within existing structures, for example, where GPs draw up practice formularies that limit the products prescribed.
As the patient’s advocate, nurses should be able to make the case for such individuals by bringing them to the attention of relevant committees, for example through reports. As part of clinical governance, it will be important for nurses to be able to use evidence to support or challenge existing standards, policies and customs.
Conversely, pressure to prescribe from team members, patients and others needs to be considered. Such pressures may take subtle forms, particularly where there are established patterns of prescribing. Job descriptions now include prescribing, with a clear expectation that district nurses and health visitors will prescribe. Prescribers themselves, with the support of their managers, will need to educate staff and patients about this role change. If gaps emerge regarding the professional management of prescribing staff, it is essential that strong and accessible support structures are in place so that prescribers can discuss their practice in a safe way. It will take time for new prescribers to build up confidence and move from competent to expert prescribers.
Before nurse prescribing, stock products (including recycled stock) were stored in clinic cupboards or carried in car boots from patient to patient. These practices must stop as they are now redundant. Nurses will need to develop new skills in refining how much to prescribe, and in some cases promoting the use of group protocols to prevent wastage. This will also mean developing and educating team members about good prescribing practices - including good use of the prescriber’s time. Time spent with patients who require prescriptions will increase and savings made in certain areas, such as fewer prescription requests from GPs, will be borne by the nursing service. This is important and should be addressed by managers in terms of clinical governance, the support provided and workforce planning.
Prescribers will need to be aware of financial pressures and to work within an agreed budget, but this may in effect result in rationed care. Nurses will need to be able to justify their prescribing patterns, including any changes made towards the end of the financial year.
3. Consider the choice of product
The rationale for the choice of product is the crux of accountability in prescribing and can easily be identified in patients’ records. To arrive at a final decision, prescribers need easy access to a wide range of reliable data sources. This includes paper as well as internet-based research evidence, texts and journals, patient records and prescribing analysis and cost (PACT) data. Prescribers should eschew samples from drug companies and avoid using company data as their sole source of information. It is best practice to cross-refer data from different valid sources.
It is essential for prescribers to have access to research data and the skills to understand what is being claimed. Prescribers are accountable for what they prescribe - this is most evident where a wide range of products are available and will become more relevant as the formulary is extended.
Until changes are made to the formulary, prescribers need to take care where products have more than one therapeutic use or route of administration. For example, some analgesics also have antipyretic properties and there is some ambiguity about whether or how nurses may prescribe these products.
Prescribers must actively assess each patient individually rather than follow a ‘set menu’ of items. Apart from clinical effectiveness, other criteria can be applied in selecting products, including cost, comfort and compliance. It may be tempting to prescribe on the basis of cost alone. But note that cost-effectiveness does not mean ‘cheaper’ as a more expensive quality product may be more cost-effective in the long term. Ease of use and the level of staffing required to apply a treatment also need to be considered and, where appropriate, commented on for auditing purposes.
Next week: exploring the four remaining principles of good prescribing.