VOL: 98, ISSUE: 43, PAGE NO: 41
DIANNE BURNS, BSc(Hons), RGN, is a specialist practitioner (practice nursing), Pennine Medical Centre, Mossley, Greater Manchester
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The role of the practice nurse has changed dramatically over the past few years: many have taken on new roles and responsibilities, and an increasing number now have a major role in the promotion of health and the management of chronic disease, running nurse-led services. Many of these nurses do not yet have prescribing rights and have been issuing prescription-only medicines to patients using protocols or patient group directions. However, practice nurses are becoming increasingly involved in influencing doctors’ prescribing decisions (Jones, 1994). Burke (1994) says that it is often the practice nurse who decides on the treatment for a patient and who writes the prescription for the GP to sign.
The recent extension of prescribing rights will allow nurses who have undertaken further training to prescribe from an extended formulary (DoH, 2002). It is vital that prescribing in general practice is examined and understood in order to provide accurate and detailed evidence to support the claims of practice nurses that certain classes of drugs should be included in the Nurse Prescribers’ Formulary.
A study was undertaken to collect data regarding the prevalence of nurse-influenced prescribing in general practice and to determine when, and how often, it occurred. A further aim was to produce information relating to the activities undertaken by nurses when acquiring prescription-only medicines for their patients and to determine the major factors that influence the nurses’ decisions regarding the prescribed treatment. The study also sought to describe the professional characteristics of the nurses involved, that is, their qualifications, the length and depth of their nursing experience, and the extent of their education on prescribing issues. A descriptive survey was carried out, consisting of an anonymous postal questionnaire and a self-report diary.
A sample of practice nurses working within a health authority in the North West of England was obtained via a computer-generated list obtained from the recently updated Family Health Services Authority database. To reduce bias, a probability sample was extracted from the list using a systematic sampling technique. Seventeen nurse practitioners were excluded from the study, leaving a total of 53 practice nurses. Each respondent was asked to complete a page in the self-report diary each time he/she influenced prescribing during one normal working week. Data were stored and analysed using a computer software program. Thirty-one nurses completed and returned the questionnaires (58.4%) and 30 nurses completed the diaries (56.6%).
Many study participants were experienced and skilled practitioners who had undertaken additional post-registration education to prepare for their role. However, none had completed a pharmacology module or the ENB Nurse Prescribing Course. Some 94% of respondents said that they attended study days provided by pharmaceutical companies two or three times a year.
The results suggest that respondents provide care within a wide range of clinical areas, and that the activity of nurse-influenced prescribing is linked to each nurse’s role within the practice. During one working week, 30 participants reported on 328 occasions when they were able to influence prescribing. These activities covered 25 different clinical areas and involved the supply of 33 different products.
The methods used by the nurses to obtain prescription-only medicines varied depending upon the clinical area in which they worked and the medication prescribed. Box 1 lists the means by which the nurses influenced the GPs’ writing of the prescription.
The respondents’ levels of expertise differed and this appeared to affect the frequency and degree of influence exerted on the GPs. However, a small number of respondents were able to exert high levels of influence even though they appeared not to have completed any recognised training programmes relating to the clinical areas concerned.
The level of control exerted by GPs was a major factor in the rate and type of all prescriptions generated, but particularly in areas of prescribing where the nurse had little or no expertise. However, in the areas of asthma, travel and family planning, GP influence was considered unimportant when deciding upon a product for a patient. In these areas, the patients themselves largely influenced the choice of product.
Many respondents used protocols to guide activities, particularly in asthma care and travel vaccination. However, this study showed that only 28% of all protocols used complied with DoH guidelines (DoH, 1999).
Few respondents reported that the British National Formulary, MIMMS or local pharmacists influenced their choice of product. Pharmaceutical companies did not appear to be an influence, either, with the notable exceptions of drugs for asthma and travel vaccination.
The results show that many of the respondents in the study were able to influence the prescribing habits of GP colleagues in a number of clinical areas using a variety of methods. Many of the participants were experienced and skilled practitioners who had undertaken additional post-registration education to prepare for their role. However, none had received specific training in pharmacology and prescribing, although it is possible that their ability to influence the prescribing habits of GPs had been developed over a number of years through a combination of specific education and personal experience. Some respondents, for instance, reported that there were times when they would discuss treatment options with GPs before obtaining a prescription. It is reasonable to assume that these nurses had acquired some knowledge relating to the products. It is also possible that the opportunity to discuss treatment decisions with GP colleagues increased the nurses’ confidence in their decision-making skills.
However, although many respondents demonstrated their ability to influence prescribing, it could be argued that it is unclear whether they had sufficient knowledge to justify this practice. It could also be argued that their education has not equipped them for this role, and that such activities are occurring without proper guidance and an adequate educational base. Furthermore, although nurses and GPs have a duty to ensure competence, it remains unclear how that competency has been assessed. Indeed, many of the respondents themselves recognised that further education or updating would be necessary if they were to assume responsibility for issuing prescriptions. In such a scenario, nurses would find it difficult to prove competence and capability if mistakes were to occur.
The matter of vicarious responsibility also needs further exploration, especially where the GP and nurse are sharing responsibility for providing a prescription. Whoever signs the prescription is legally responsible, but the situation becomes more complicated when the nurse writes the prescription and the GP signs it. While the GP is vicariously liable for the actions of a negligent employee, accountability issues are unclear, and the nurse remains accountable to the law, the UKCC (now the NMC), his/her employers and the patients (UKCC, 1992a; 1992b).
This study demonstrated that nurse-influenced prescribing in general practice was a common occurrence. It appeared to offer nurses an opportunity to respond to their patients’ needs, particularly in the areas of asthma, diabetes, travel vaccination, family planning and wound care, where the nurses had taken on additional responsibility for patients’ care.
It is likely that, given access to educational preparation and support, nurses will benefit from the newly extended prescribing rights either as independent or supplementary prescribers. Indeed, it could be argued that additional training is necessary because they are influencing prescribing and that they should, therefore, have a detailed knowledge of the properties of the products being prescribed. This would enable them to develop a deeper understanding of the complexities and responsibilities involved in prescribing and allow them to take full responsibility for their actions and decisions. However, many practice nurses will require access to medicines and products that have not been included in the extended Nurse Prescribers’ Formulary, and in its present form it could be argued that it remains too restrictive, particularly in areas such as asthma and diabetes management and the treatment of minor illnesses.
This study supports the argument that practice nurses should be included or considered within the new nurse prescribing proposals. My recommendations as a result of the study are detailed in Box 2.
Next week: Extended prescribing powers: Three views