How can we work together to ensure that we maintain competency, access continuing professional development (CPD) and make sure patients get good care, in what is likely to be an increasingly difficult financial situation? asked Barbara Stuttle, ANP Chair, at the end of the ANP’s lively regional conference on ‘Ensuring Safe Prescribing Practice’, held in London on 26 November.
She urged her audience to start preparing to persuade managers that CPD is a right, not a luxury, as budgets tighten: CPD is essential to ensure continuing safe practice. Several nurse prescribers in the audience had funded their attendance and taken annual leave to attend. She also stressed the importance of making notes, recording incidents and – sometimes – challenging colleagues and changing practice.
The conference was chaired by Baroness Cumberlege, Patron of the ANP, who highlighted the tremendous progress made in the last 20 years, from a situation in which no nurses prescribed and queues formed outside doctors’ doors for them to sign prescriptions for unseen patients. The BMA’s fears that opening the formulary was dangerous have proved unfounded and soon, it is hoped, controlled drugs will be available too (see here).
Baroness Cumberlege stressed the importance of trust, a theme that cropped up throughout the day, and looked to the day when multiprofessional education becomes the norm.
Trust and confidence take years to build up but can be destroyed in an instant, pointed out Mark Gagan (senior lecturer, Bournemouth University) in his talk on legal developments in nurse independent prescribing. Following a series of scandals, the professions now need to restore public trust, and nurse prescribers must be able to justify what they do, both to build and maintain trust and confidence and for legal reasons. The work of the Nursing and Midwifery Council (NMC), Health Professions Council and the Council for Healthcare Regulatory Excellence highlights the increasing importance of regulation. Accountability is key: to the patient, criminal law, civil law and employer and, some say, to oneself.
For negligence claims, the claimant must prove that: a duty of care existed, the defendant breached the duty of care and was careless, and that carelessness caused harm to the claimant. Mark highlighted the importance of:
- Not giving casual advice to friends and neighbours.
- Checking adequate cover for damages is in place especially for those nurse prescribers working in GP surgeries or independently.
- Good record-keeping.
- Evidence-based practice (actions must have sound logical basis).
Turning to recent legislative developments, Mark examined the workings of the Mental Capacity Act and how competence is defined, the use of advanced directives, lasting power of attorney, and the current situation about mixing medicines and controlled drugs (see here and here).
A rich picture of the impact of the impact of nurse prescribing on service delivery is emerging, said Molly Courtenay (professor of clinical practice: prescribing and medicines management, University of Surrey), from her research in different therapy areas since 2004. Molly and her colleagues have looked at pain, dermatology, children and diabetes care, and have used a variety of methods to try to establish how the rollout of nurse prescribing is working in practice in different areas.
The data have provided evidence about how nurse prescribing is working from the following standpoints: efficiency and access; quality of care; safety; the impact on the team and changing models of care; and the support needed.
Less time being spent in waiting for doctors’ signatures, increased capacity partly through better use of skills in teams (for example in diabetes where nurses, nurse practitioners and doctors are seeing different groups of patients) and partly through enabling nurse-led services (for example, in dermatology), and improved access to medicines, have all boosted efficiency and access. The impact on the quality of care has also been positive, as nurse prescribers can complete episodes of care, and provide continuity of care and a holistic assessment: adherence to medicines and better prescribing decisions may both result from these changes.
Safety concerns have been much discussed since nurse prescribing was introduced but the evidence here, too, is reassuring: nurses are picking up errors, are prescribing safely, and have a tendency to stick to guidance, leaving more complex cases where this may not be appropriate to medical colleagues.
Professional roles have shifted, with doctors no longer signing prescriptions for patients they have not seen, and having time to concentrate on the more complicated cases. For diabetes specialist nurses, the prescribing qualification is becoming essential for career progression but in other areas, non-nurse prescribers are happy not to prescribe. In an interesting development, medical students from Cambridge University are attending a non-medical prescribing programme.
Support, as ever, is necessary but is still lacking in some areas. As well as CPD, supervision, and peer support, organizations need to make sure that policies and clinical governance are in place as non-medical prescribers come through the prescribing programme and that workforce planning considers the use of their skills. There is some evidence that pharmacist prescribers are not prescribing once they have qualified as their role, and the services they could deliver, have not been defined in advance.
Accountability, the evidence base, and good record-keeping were again highlighted by Fiona Culley (professional advisor, NMC), as she talked about developments in nurse prescribing from the perspective of the NMC. There is no room for “confusion and creativity” in prescribing and complacency and fear need to be balanced. Prescribers should review their prescribing practice in the light of the Code of Conduct and consider the various standards taken together. Interestingly, although prescribers now form nearly 10% of the register, and the NMC has 6-8 fitness to practice hearings a day, nurse prescribing has not been an issue.
Next year, nurse prescribers should look out for several developments on the NMC website: the next stage of consultation on pre-registration education; revised standards of proficiency for nurse and midwife prescribers; and progress on revalidation.
What is polypharmacy, how much of a problem is it for older people and how should it be tackled, were among the important questions addressed by Lelly Oboh (consultant pharmacist for older people, Lambeth PCT) in a fascinating talk that set out clearly exactly how older people in particular end up taking so many medicines, and the consequences it can have for them.
Polypharmacy can be defined as being on many drugs at the same time (usually four or five) but can also be seen as people being on any medicines they should not be on. To put the issue in context, 15% of over-75s in the community take five or more medicines, and nursing home residents take an average of six to eight and sometimes up to 20 medicines. In some cases, these may all be needed and valid but polypharmacy does have all sorts of negative consequences including more and longer hospital stays and poorer quality of life. Regular, thorough, medication reviews, good communication and record-keeping, alongside a wealth of other strategies, were set out by Lelly as ways of reducing polypharmacy.
There are lots of reasons why polypharmacy arises, particularly in older people, including multiple clinicians prescribing for the same patient, drugs becoming more available without prescription, multiple pathologies, and the impact of targets. It can be important to resist the temptation to prescribe and sometimes it is necessary to make difficult decisions about risks and benefits (which, again, should be carefully documented). Prescribers should think holistically, balancing efficacy of treatment with quality of life.
Older people have increased sensitivity to some drugs and can have impaired pharmacokinetics so, for example, the effects of sedatives can last longer, causing drowsiness and making falls more likely. For these and other reasons, they are often at increased risk from the effects of polypharmacy.
Medication errors are everyone’s concern, said Matt Griffiths (senior nurse, medicines management, University Hospitals of Leicester, and visiting professor, prescribing and medicines management, University of Northampton) in his session on medication errors and safety. He discussed the ‘Safety in Doses’Â reports (one covering 2005 and half of 2006 and one covering all of 2007) from the National Patient Safety Agency, which make sobering (and worthwhile) reading but do contain some good news. Reporting of medication incidents has increased, and after earlier guidance on the safe use of potassium chloride injection and oral methotrexate, the report covering 2007 contained no incidents of death or serious harm involving these medicines.
The earlier report highlighted the fact that two groups of patients are associated with medication errors. One is people with allergies receiving a medicine to which they are known to be allergic (these accounted for only 3.2% of all hospital incidents but one-third of these caused harm). The other is children – children up to four years were involved in 10.1% of incidents where age was stated.
Matt looked at the different types of medication incidents – using examples that provoked gasps from the audience – and then at the key actions for improving medication safety. For example, one action is minimising dosing errors – but how is this actually done? Yes, use information, training and tools, direct efforts at high-risk patients (such as children) and high-risk drugs; but what about double checking – is it really independent or do we tend to assume that someone senior is better at the maths? What if it is simply impractical to double check every time because the regimen is so involved? Another action is ensuring medicines are not omitted and Matt explained how his Trust has introduced a system for patients self-medicating while waiting on admission, if the admission is nothing to do with medication and the patients are capable.
The tremendous progress made in nurse prescribing as well as the importance of good record-keeping, communication, evidence-based practice, and updating, were highlighted again and again during the day, which concluded with a choice of workshops on CPD using disease-specific case studies and decision-making processes. Look out on the website for news of the 2010 events – and come and see for yourself. Lowri Daniels