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Embrace your autonomy: be proud to be a nurse prescriber! All new specialist community public health nursing students about to undertake the V100 prescribing course and those who have recently qualified as community practitioners should embrace their prescribing role, says Louise Perrin.

As a new nurse prescriber be reassured that your knowledge will be current and up to date, as well as grounded in your past practice.

As a registered nurse or midwife you will have already practised and developed both your knowledge and skills of the consultation process, assessment, care planning and medicines management.

The V100 course is a natural progression in developing your practice, skills and knowledge as you move into public health as an autonomous practitioner.

BACKGROUND

Nurse prescribing first came about following the Cumberlege Report, Neighbourhood Nursing: A Focus For Care (Cumberlege, 1986), which recommended that nurses should be able to prescribe from a limited formulary. The Crown Report (DH, 1999) later endorsed nurse prescribing, and nurses were finally recognised for the important role they were already playing in both prescribing and in health promotion.

First, there was a pilot project and then further groups were targeted in 1999 before prescribing was rolled out in 2001. The initial pilot projects identified nurse prescribers' anxiety as an issue due to their concerns about accountability (Luker et al, 1997). Subsequently, Lord Darzi's report, A High Quality Workforce: NHS Next Stage Review (DH, 2008) provided a focus on the NHS, increased funding and the empowerment of staff to take up training and education. This formally recognised continued professional development (CPD) as 'vital' to professional practice. If you have been fortunate enough to secure or have recently completed a nurse prescribing module, take advantage of this exciting opportunity to develop your role and keep sight of the benefits of prescribing.

PRESCRIBING PRACTICE

The Nursing and Midwifery Council (NMC) publishes regular reports on its members. The statistics show a gradual increase in registrations of nurse prescribers each year. The most recent showed that in 2010, there were more than 54,000 nurse prescribers (Royal College of Nursing (RCN), 2012). However, Hall et al (2006) suggest that only 50% of health visitors with a V100 qualification prescribe for their clients, and further studies cite evidence of a low level of prescribing activity (While and Biggs, 2004; Thurtle, 2007, Young et al, 2009; Brooks, 2013).

While we are aware of poor engagement in prescribing there has been little research to actually explore the reasons for this. A study by While and Biggs (2004) provides us with an insight into the prescribing habits of health visitors. They conducted a postal study of health visitors and district nurses in three PCTS in south England and found that 56.8% wrote up to one prescription a week; 23% wrote between one to three a week; and 8% had never prescribed since completing their training. Prescribing was higher among district nurses than health visitors. It is interesting that over two-thirds reported that the Nurse Prescribers' Formulary (NPF) (British Medical Asssociation (BMA), 2013) did not cover their prescribing needs and gave examples of products they would like to be able to prescribe, including antibiotics, analgesics, treatment for diarrhoea, allergic rhinitis and creams for the skin. Perhaps the NPF could be expanded on if more practitioners were to use their prescription pads in the first instance.

BENEFITS AND BARRIERS

There is evidence that nurse prescribing has led to improvements in patient-centred care, access to appropriate health care, patient safety and the reduction of GP appointments (RCN, 2012). These were the primary aims of nurse prescribing being established, along with reducing GP waiting lists and creating a flexible and responsive workforce (Bradley and Nolan, 2008).

Research has focused on identifying barriers to prescribing for health visitors, including:

* Time to write prescriptions, especially in a busy clinic

* Lack of confidence

* Lack of time to document in clients' and professional records

* Lack of advice and training

* Lack of support from other practitioners (While and Biggs, 2004).

More recently, Thurtle (2007) identified the absence of a 'prescribing culture' within health visiting, although there was optimism that this could be a possibility. She conducted interviews with health visitors and their managers in one PCT and found that there was a need for improved communication and structures to support the culture of prescribing, noting that practitioners needed to be active in their own learning.

A recent project to address low prescribing activity provided clinical updates and reduced delays in receiving prescription pads for health visitors in an inner city location. This led to increased prescribing confidence and prescribing activity (Brooks, 2013).

HOW TO GET AHEAD AS A STUDENT

There are so many opportunities for you to observe and reflect on your role as a nurse prescriber. As a student you may find that your practice teacher does not prescribe and you feel at a disadvantage over your colleagues. This should not deter you from your goal of successfully completing the V100 course to become a competent nurse prescriber.

Health visitors assess both mother and baby during each consultation, and you can highlight key experiences and log your prescribing hours through your attendance at child health clinics, and observing new birth and six-week contacts. You will be observing and then practising; first supervised and then unsupervised once you become competent in your practice.

You can start seeking out learning opportunities by arranging to observe other prescribers in the community setting, such as pharmacists, GP consultations, family planning nurses, practice nurse prescribers, community nurses, district nurses, mental health practitioners, school nurses and specialist nurses, for example, consultations in allergy or enuresis clinics.

Become more familiar with your NFP and prescription pad; take out copies of a blank FP10 form to practise writing prescriptions during your day in practice. Talk to other nurse prescribers and observe others -even if they do not prescribe they are conducting consultations all the time and signposting clients to the appropriate agency for treatment, which is an integral part of the prescriber's role.

PRACTICAL ADVICE

On qualifying it is imperative that you embrace and take responsibility for your own CPD. Maintaining competence is a requirement to remain registered as a prescriber. No one else can or will do it for you, so you can start by prioritising any opportunities for support, such as clinical supervision, preceptorship and attending prescribing updates or forums. You can keep yourself up to date with prescribing practice and knowledge through national and local guidelines, such as MeRec Briefings from the National Prescribing Centre (NPC). Use reflection to make action plans to identify further support or training. In reality this is not always easy; you will be presented with huge demands on your time and will often feel overwhelmed by the pressures of autonomous working and managing your time and diary. There will be a period of adjustment into your new role and this may even be in a new base, trust or team.

If you use these opportunities as a newly qualified health visitor these practices will soon become engrained in your practice and time management skills. Research shows that the designated leads for prescribing do not actually have stipulated time for this role (Courtenay et al, 2011) and this would explain the lack of structured support some health visitors are highlighting as a barrier.

Keep the momentum going

As a newly qualified health visitor and nurse prescriber your head will now be full of measurements, calculations, adverse drug reactions, contraindications, treatments and applications for a range of different conditions. This is in addition to knowledge of National Institute for Health and Care Excellence (NICE) guidelines, national and local policies and procedures, concordance, record-keeping and information governance. How do you now start to use your knowledge and gain confidence to write your first prescription? If you do not keep the momentum going you are more likely to forget your newly acquired knowledge and put prescribing to the back of your mind.

Identify your personal barriers to prescribing

The products you are able to prescribe are limited and the more you practise the more familiar you will become with these products. I have found that clients do not mind waiting longer and I do not let this deter me from prescribing. If you deliver an effective consultation, which provides the patient with accurate, evidence-based and appropriate advice, you may or may not decide to prescribe at the end.

Writing a prescription only takes a minute--it is the consultation that is the crucial and lengthy process. During the consultation you must elicit the relevant information to make a clinical decision. Each consultation in clinic is important to each client and they will come back to the clinic and wait again (or invite you back into their home) if you are able to develop a relationship based on trust and they feel they are being listened to.

Discuss with colleagues and other medical and non-medical prescribers

On qualifying, it is likely that you will have to wait for your prescription pads before you can actually prescribe (David and Arena, 2000). It will be easy to put prescribing to the back of your mind while you become immersed in your practice at this time and I have observed this in my recent practice as a community practice teacher (CPT).

However, you can use this interim time to make a start by meeting with GPs, the primary care team you are linked to and a local pharmacist. Make the most of primary care team meetings to discuss prescribing practices or set up one-to-one meetings. You can also have ad hoc discussions with health visitor or other nurse prescribing colleagues to explore their prescribing practices for different conditions; for example, management of oral candidiasis, eczema or head lice.

Keep a reflective journal and reflect on your experiences

Keep a journal to make notes for your prescribing. A student who is new to prescribing will often ask, 'What do you prescribe for eczema?' It is natural to search for the 'correct' answer. Remember that every client, assessment and presentation of a condition is different. Through your module and in practice you will be encouraged to actively seek out the best evidence-based practice.

Follow the 'seven principles of good prescribing' (NPC, 1999) and, remember, the prescription is only one part of this process. Focus on the consultation itself. Continue to reflect over your experiences in practice, your assessments and the advice you give to clients.

It is important that health visitors recognise how their prescribing skills impact on and enhance their practice. For example, you will meet clients and their families who have been diagnosed with medical conditions and are already having their care managed and medications reviewed by their GP or a consultant. This may be asthma, eczema, epilepsy, mental health conditions, diabetes, respiratory or cardiac conditions, among others. The community practitioner is in a position to offer opportunistic health promotion advice and education.

It is extremely common to find yourself discussing the use of prescribed paracetamol and over-the-counter medicines with clients. There will be opportunities to act as an advocate for your clients with mental health issues and it is not unusual to find yourself observing children's inhaler techniques and discussing antibiotic use and misuse

MOVING FORWARD

You should feel ready and able to start prescribing when you receive your prescription pad. Don't delay, as you may then start to lose confidence in your abilities. If you keep sight of all the benefits to prescribing and the new knowledge you have gained, and take responsibility for your own professional development, this role can be incredibly rewarding and increase your job satisfaction. You will gain confidence as you continue your prescribing practice and you will, in turn, become a positive role model for your colleagues who are not using their prescribing privileges. If you start to create a prescribing culture in your team, others will follow your lead.

REFERENCES

Bradley E, Nolan P. (2007) Impact of nurse prescribing: a qualitative study. J Adv Nurs 59(2): 120-8.

British Medical Association (BMA). (2013) Nurse Prescribers' Formulary. London: BMA.

Bradley E, Nolan P. (2008) Non-Medical Prescribing; Multidisciplinary Perspectives. Cambridge University Press.

Brooks C. (2013) Developing health visitor prescribing. Community Pract 86(4): 28-30.

Carey N, Stenner K. (2011) Does non-medical prescribing make a difference to patients? Nurs Times 107(26): 14-6.

Courtenay M, Carey N, Stenner K. (2011) Non medical prescribing leads views on their role and the implementation of non medical prescribing from a multi-organisational perspective. BMC Health Serv Res 11: 142.

Cumberlege J. (1986) Neighbourhood Nursing: A Focus For Care. Edinburgh: Department of Health and Social Security.

David A, Arena A. (2000) A prescription for change--nurse prescribing. Nurs Times 96(47): 19.

Department of Health (DH). (1999) Review of prescribing, supply and administration of medicines (the Crown Report). London: DH.

DH. (2008) A High Quality Workforce: NHS Next Stage Review. London: DH.

DH. (2009) The Healthy Child Programme: Pregnancy and the First Five Years of Life. London: DH.

DH. (2011) The Health Visitor Implementation Plan 2011-2015: A Call to Action. London: DH.

Hall J, Cantrill J, Noyce P. (2006) Why don't trained community nurse prescribers prescribe? J Clin Nurs 5(4): 403-12.

Luker K, Austin L, Hogg C, Ferguson B, Smith K. (1997) Nurse prescribing: the views of nurses and other health care professionals. British Journal of Community Nursing 2: 69-74.

National Prescribing Centre. (1999) Prescribing Nurse Bulletin. Available from: www.npc.nhs.uk/non_medical/resources/nurse_bulletin_vol1no1.pdf [Accessed October 2014].

Nursing and Midwifery Council (NMC). (2006) Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. London: NMC.

Morton S, Bowes N, Leech S, Smith K. (2011) Starting with support. Community Pract 84(11): 40-1.

Royal College of Nursing (RCN). (2012) RCN Fact Sheet: Nurse Prescribing in the UK. London: RCN.

Thurtle V. (2007) Challenges in health visitor prescribing in a London primary care trust. Community Pract 80(11): 26-30.

While AE, Biggs KS. (2004) Benefits and challenges of nurse prescribing. J Adv Nurs 45(6): 559-67.

Young D, Jenkins R, Mabbett M. (2009) Nurse prescribing: an interpretative phenomenological analysis. Primary Health Care 19(7): 32-6.

LOUISE PERRIN MSc PGCE BSc RN RHV Lecturer, Anglia Ruskin University Faculty of Health, Social Care and Education Bank Health Visitor at SEPT
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Author:Perrin, Louise
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Date:Feb 1, 2015
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