Prescribing by Community Nurses
This article demonstrates that nurse prescribing has the potential to become an essential part of the district nurse/health visitor role. Ongoing support groups will enable patients to receive best practice outcomes from well trained and supported professionals. It has been noted that nurses who frequently prescribe, worked in teams where their colleagues were also actively prescribing. Peer support offers the opportunity to foster a learning culture amongst colleagues and a vehicle for reflective practice. It was evident that staff are eager to keep themselves updated by the increased attendance rates at the two support groups, however, the request to practise prescription writing at every meeting indicates that confidence levels are still low. The Trust, however, are committed to ensuring that nurse prescribing is an ongoing training issue, with attention being given to offering an ongoing educational programme to meet the needs of its workforce, by the deliverance of support groups at a convenient time and varied location.
One of the key drivers for change within community nursing practice in the last decade has been nurse prescribing. The Medicinal Products: Prescription by Nurses etc. Act (1992) allowed district nurses (DN's), health visitors (HV's) and practice nurses who held either a DN or HV qualification, to prescribe from a limited formulary. Following successful evaluation of the pilot sites, nurse prescribing using the nurse prescribing formulary (NPF) was introduced nationally (Luker et al., 1998). Within Wales, the first cohort of DN's and HV's qualified as prescribers towards the end of 2000.
Recent policy documents imply that nurses' skills and experiences should be developed to deliver high quality care in particular areas where patient care can be most influenced (DoH, 2004). The Welsh approach is steered by the Review of Health and Social Care in Wales (Wanless, 2004) and Designed for Life: Creating World Class Health and Social Care for Wales in the 21st Century (WAG, 2005). Nurses therefore need to understand the political agenda to enable them to drive practice forward. Nurse prescribing should be an ideal vehicle for this as it is an essential tool to an already complex toolkit. However, within Wales, it is acknowledged that updating of nurse prescribing is poor. At last years nurse prescribing conference in Wales, Rosemary Kennedy (Chief Nursing Officer for Wales) indicated that it could be argued that DNs and HVs were not the ideal group to take nurse prescribing forward in Wales, however, we are here, we are trained but we are not prescribing to our potential.
Background
Within Bro-Morgannwg NHS Trust it was recognised that the uptake of nurse prescribing was low and despite having informal peer support groups in place, there was no improvement in prescribing habit. Therefore, in October 2004 we decided to find out why nurse prescribers were not actively prescribing. A small-scale survey of DNs and HVs with the nurse prescribing certificate was undertaken to understand prescribing patterns and reasons for non-prescribing. One hundred and twenty questionnaires were distributed to all DN/HV's throughout the Directorate, of which a total of 92 were returned. The questionnaire took the form of four questions (Table 1).
Question One– Frequency of prescribing:
Of the 92 responders, 57.6% were currently prescribing; 79.8% of the 57.6 had prescribed within the last month with 60.7% prescribing within the last week, and the reasons for not prescribing are identified in Table 2.
Question Two– Your last prescription:
Products were prescribed from the formulary, ranging from wound care, emollients, drugs for head lice and analgesia. However, it was highlighted that the majority of prescriptions written were for wound products.
Question Three– Attendance at support groups:
Fifty four per cent of responders had previously attended support group with all participants finding it useful. The
- Lack of confidence due to the delay in receiving prescription pad post qualification.
- Administration issues (easier to get the GP to prescribe, existing process meets the needs of the patients).
-Not currently in clinical practice.
-Workload constraints.
-Limited opportunity.
-Newly qualified, awaiting prescription pads.
reasons for non-attendance included inconvenient day and location.
Question Four– Ongoing support group:
Almost 96 per cent of responders felt there was a need for a support group with 89 per cent prepared to attend a quarterly meeting. Some responders indicated that they would also be happy to seek out alternatives (Table 3).
Findings
The responses, as they were geographically returned, made some interesting reading (locations will be referred to as site A and site B). Only 42 per cent of site A responders were actually prescribing as opposed to 76 per cent at site B. Of the 42 per cent, only 42 per cent prescribed within the last month compared to 87 per cent of the 76 per cent at site B. What makes this more interesting is that 60 per cent of those at site A actually had attended a support group, whereas only 47 per cent at site B had previously attended a support group. On more detailed analysis it was apparent that those nurses who were frequently prescribing tended to work in teams that included other nurse prescribers, this is supported by a similar study undertaken by Otway (2001). Her study of 350 nurse prescribers found the more active prescribers worked in teams that were considered to be cohesive and supportive, working in a framework of reflective practice and peer group support. Previous evaluations of nurse prescribing recognised the importance of clinical supervision and mentorship but did not highlight the significance of informal peer support (Luker et al., 1997; Blenkinsopp et al., 1998). Otway (2001) concluded that cohesive and supportive teams are a valuable asset to the development of innovative practice but recognised this type of support is not available to every nurse prescriber.
Support group
Based on the outcomes of the questionnaires, we were mindful of capturing the enthusiasm of the staff, clearly indicated by the high response rate. To demonstrate the commitment of both the Trust and our commissioning bodies, it was felt essential to liaise with the pharmaceutical advisors across both our Local Health Boards (LHB) to drive forward nurse prescribing. Using a collaborative approach we planned an initial meeting to identify the needs of our nurse prescribers.
Please respond by ticking or circling the appropriate box:
1. / Are you currently prescribing?
If yes, when did you write your last prescription?
One week / one month / 3 months / longer
If no, why not? Please give reasons. / YES / NO
2. / What was the last product that you prescribed?
3. / Have you previously attended any nurse prescribing
support groups?
If yes, was it useful? Sometimes / Always / Never
If no, please give reasons. / YES / NO
4. / Do you feel there is a need for ongoing support groups
If yes - will you attend a quarterly meeting
If no - what are the alternatives? / YES
YES / NO
NO
Recognising that our objective was two fold, we wanted to meet staff needs as well as driving forward the initiatives from the South East Wales Nurse Prescribing Forum to enable us to motivate nurse prescribers and standardise practice in Wales. The South East Wales Nurse Prescribing Forum was established after the implementation of Nurse Prescribing in Wales in 2000. This group consists of designated nurse managers, pharmaceutical advisors, educational leads and commissioners who all have responsibility for nurse prescribing in their areas. The objective of the group is to steer and support nurse prescribing, initially with limited DN/HV prescribers, but now also with supplementary prescribers. In 2004, the group pioneered a South Wales Nurse Prescribing Policy and competency framework, which has been implemented across the majority of Trusts in the South Wales region.
The initial meeting was well attended and consisted of experienced and novice prescribers and facilitated excellent discussion via group work as identified in Table 4.
We proceeded to establish quarterly meetings of two-hour duration in the format of one hour educational and one hour clinical with each session being evaluated. A key factor to the attendance of previous support group meetings was inconvenient day and location. Therefore, the quarterly support group programme is designed to maximise attendance by utilising a different day, time and venue in order for both disciplines to attend. The Trust has taken the stance of stating that in accordance with continuous professional development, nurse prescribers must attend at least one session annually. Thus ensuring nurse prescribers review and update their prescribing skills and knowledge within a framework of clinical governance (Lawton, Cantrell & Harris, 2000).
Prescription writing
The group requested prescription writing at this initial meeting and stated that the benefit of undertaking this at each meeting would promote confidence in prescribing. Humphries and Green (1999) recognised the legal implications invoked anxieties within the nurse, as in a court of law our actions are comparable to our medical colleagues. Accountability is inherent in all aspects of nursing especially nurse prescribing. Historically, district nurses and health visitors were seen to be the expert within the community setting on making clinical decisions such as wound product
selection and skin care etc and used to actively write a prescription but asked the GP to sign and this was accepted practice. The advent of nurse prescribing aimed to legitimise this role. However, the accountability surrounding prescription writing has invoked increased anxiety in this same group of staff.
Peer support
Informal support is an effective method of supporting nurse prescribing (Otway, 2001). The evidence within the Trust supports Otway's study in the year 2000 which demonstrated that active prescribers worked in teams that included other prescribers. Teamwork provides cohesion and a vehicle for reflective practice and conversely those who describe themselves as isolated practitioners were resistant to prescribe. The informal capacity to reflect in and on action (Schön, 1983) and informally share experiences with peers is fundamental to developing nurse prescribing. It was apparent during discussion within the support group that the benefit of novice and experience prescribers working together nurtures prescribing.
Continuing professional development (CPD)
Nurse prescribers have a professional duty to maintain their prescribing competence and must strive to achieve this as part of CPD and lifelong learning. The employer must support the maintenance of competence in line with clinical governance and foster a learning culture (NMC, 2002; Basford, 2003). The philosophy of the support group aims to facilitate this for staff.
The publication Maintaining Competency in Prescribing (National Prescribing Centre 2001a) provides a framework to assess knowledge and skills of practitioners. This work has been adopted by the South East Wales Nurse Prescribing Forum and incorporated into the nurse prescribing policy. Therefore, at the subsequent meeting, staff had the opportunity to complete the framework. Evaluation demonstrated that group work was beneficial to practitioners in completing this exercise and enabled them to identify their individual action plan to enhance learning. The NHS Knowledge and Skills Framework (NHS KSF) and the development review process support the effective development of individuals with managers and staff being clear about role expectation. The inclusion of nurse prescribing competence on personal development plans identified, as part of the individual performance review process will further highlight individual training need and influence the proposed agenda for subsequent support group meetings.
Conclusion
District nurses and health visitors are in the enviable position to be able to drive forward the potential complex care package, capable of being offered to patients and clients alike within the community setting. Within that package, it is essential to remember that nurse prescribing is already part of our expanding toolkit. Community nurses need to develop their skills to meet the challenges and be able to deliver a one-stop package of care. Maintaining competence is not an option it is obligatory. It is necessary that employers encourage staff to access ongoing support groups. The provision of an educational programme, at a convenient location and suitable time is paramount when encouraging staff to maintain or develop their competencies. Despite this, it is equally important that staff remember that it is one's own responsibility to ensure that we (nurses) act in a professional manner at all times, thereby promoting professional integrity. It has been noted that the more you prescribe the more confident you become. It is hoped that the benefits of the effectiveness of ongoing support groups will enable patients to receive best practice outcomes from well-trained and supported professionals. Supplementary prescribing has commenced in Wales. For many community nurses there is no need yet to consider this additional training as currently there may be no opportunity to use the skill but for others there is certainly the capacity to become an important element to the changing dynamic role of the community nurse in the provision of best practice.
References
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