Far North nurse practitioner Adrianne Murray is the pragmatic but passionate face of nurse prescribing. FIONA CASSIE talks to the country’s second ever-prescribing NP about doing the groundwork to be a prescriber.
So how does Adie Murray know nurse prescribing can make a difference?
Maybe when blokes whose medical notes have gathered dust for up to two decades started fronting up to her outreach clinic at an isolated Far North bay.
And then their truck-driving mate - who has turned a blind eye to his diabetes diagnosis for years - turns up soon after.
Then another mate follows and tentatively agrees to start medication for his long untreated hypertension and maybe his diabetes the month after.
“You bring in their notes and find for ten or up to twenty years they have had untreated hypertension or untreated diabetes and you are starting work with these guys from scratch,” says Murray – a whanau ora NP for Kaitaia-based Maori Health provider Te Hauora O Te Hiku O Te Ika.
For whatever reason, Murray says these hard-to-reach patients – mostly Maori men aged 30 to 60 – have let sometimes multiple co-morbidities go untreated or undiagnosed for years. But since 2002, first as an outreach clinical nurse specialist and from 2005 as a prescribing NP, she has become a familiar and trusted face in her ‘clinic on wheels’ and these men have been slowly but steadily seeking help.
“I think that was one of the initial pushes of wanting NPs - particularly in primary health care - was that we were nurses who were community-driven; who had intentions of staying in our communities so we were going to become regular providers and a face that was going to be there all the time.”
Murray says it may also help that her van clinic isn’t a conventional general practice setting and the guys get to deal with “a very down-to-earth, straight-talking whanau ora NP who loves fishing”, but she has got Maori men willing to talk about their health problems.
“A patient’s wife, actually said, ‘my husband would never go on medication for his health problems, so when I heard he’d started treatment for it, and then had been to see you three times for follow-ups, I thought I’d better come see who this nurse was, (she) must be pretty good’...”
Wake up and smell the roses
For Murray it is payoff for a decade of hard work – first doing the groundwork of networking and building the trust of the GPs, pharmacists and other health professionals she works in everyday collaboration with, then raising awareness of the NP role in the community and lastly letting her work ethic and work speak for itself. “And I believe it has now.”
Focused and pragmatic she had negotiated an NP job and funding for herself long before gaining registration as an NP. And she advises others they need to put in the hard yards in groundwork if they want to step up to working at an advanced level. “You really have to network and collaborate and do that hard”. And to those who think it should be more straightforward…
“Wake up and smell the roses – this is the world in which you are going to work in, this is the world that you have chosen to step up to the plate to,” says Murray. She says it’s not only tough for nurses but also new GPs –all new prescribers have to network and build professional trust.
As a pioneer prescriber she says what she did find surprising in the early days was having to convince some of her own nursing peers about the benefits of nurse prescribing – an issue that has gone away with time.
Prescribing barriers do remain for NPs but Murray says it’s a “huge improvement” on when she first started and there is a willingness from Pharmac to work on overcoming issues like electronic access to special authority medications. And the hopefully imminent passing of the long awaited Medicines Amendment Bill will open more doors when NPs become authorised prescribers.
“She has been a long haul and I will be celebrating when that comes through for sure!” says Murray. Frustrated at the beginning by the delays she says when you compare New Zealand to the USA - where several decades on there are still states where NPs are unable to prescribe – “we’ve really come a long way”.
A down-to-earth straight talking NP
With eight years of prescribing behind her she has also come a long way in developing her prescribing culture for the three communities she serves each week. In two of those communities she works in collaboration with a local general practice and GP and the third is the isolated Far North Bay where she runs the weekly outreach clinic from her van and has her own enrolled population.
She cares for infants to the elderly and all in between. And she says she cannot stress the importance enough of NPs like herself being able to provide on the spot prescriptive care to rural families – particularly those without a car or a registered car –when getting to their closest general practice is often not practicable or even possible.
Murray also loves the clinical and personal challenge of bringing Maori men back into the health care fold after a decade or more of untreated chronic conditions.
Once back through the door she doesn’t aim to shock them but she is very straight about the risk they face if they walk out the door and don’t return.
She takes the time to sit down and explain their condition and discuss their test results. Then she tells them the rest is up to them.
“I say ‘if you have a heart attack it’s not going to personally affect me, if you have a stroke it’s not going to personally affect me. It’s all about you’.” And she brings home Adie-style some of the down-to-earth implications of not treating their conditions… including who would look after them or their kids if incapacitated by a stroke.
“I say to the guys that I’d like to be walking around, showering myself and wiping my own bum…that’s how I like to see my life.”
Telling men their CVD risk is in the danger zone of 20 per cent plus or their blood sugar readings are high doesn’t sink in for most men as they can’t feel anything and it isn’t immediately impacting on their day-to-day life, says Murray. But bringing it back to the personal level sometimes does. Including pointing out to patients who drive big trucks for a living that if they have out-of-control blood sugars then their license and job could be on the line.
Getting patients back on the page
Having got them open to considering treatment Murray says she weighs up very carefully the best prescribing path for patients ‘coming in from the cold’.
They generally now face two or three chronic conditions – some known and some unknown – and many aren’t ready to face being sent home with multiple medicines. Particularly as some have had an adverse reaction in the past on day one of a medication and thought ‘bugger that I’m not going to have that again it nearly killed me’.
So for some, Murray believes, the safer option is to start slowly with just one condition at first, talking through very carefully about the medication and dosage level and always encouraging phone feedback so she can monitor those early days of treatment very closely.
“It’s so important to do the follow-up stuff - you have one bad reaction and you can lose them (again).”
“So I say ‘phone me there’s the number and in the first week I want to hear how it’s going … and if I don’t hear from you after ten days I’m going to ring you anyway. So I say ‘don’t waste my time …call me…otherwise I’m going to track you down anyway’ – and we have a laugh.”
Once having successfully kickstarted treatment of one condition and got the patient ‘on the page’ she and the patient can look to move on to treating the second or third condition also.
She will always advise the patient which she believes is their highest health priority but is ready to listen if they choose to start with their diabetes rather than their high blood pressure.
“As starting at some point is better than starting at no point.”
Case reviews and collaboration
She says such prescribing decisions have been questioned during case reviews with her medical colleagues who say “but Adie we need to tackle this and this”.
“Which is good, but I document really well why I haven’t. ‘I gave them the choice and they didn’t want to’. I explain that the patient said it was more important that we tackle this condition first.”
And such prescribing decisions are never taken lightly. For Murray prescribing is “huge” and she relishes the challenge of using her knowledge and skills to get the best prescribing outcomes she can for her patients.
“I’m always thinking do they live alone, do they have a support, do they operate a digger, are they a truck driver? You have to make it individual …
“I think that’s the challenge of the work because we are all different as people – we all have different wants and different needs and medicine should cater to suit us.”
With a frail and elderly mum she always relates her prescribing back to personal experiences. “And if you want your loved one to have the best experience of any medicine that they have, then why wouldn’t you do that with your own patients?”
She not only loves the human side of prescribing but also the science. “I’ve always loved medicine…I never want to leave it. I love the complexity of it.”
She also respects the need to work collaboratively with her GP colleagues to get the best for her patients. “I have regular case reviews you have to – where I work it is not uncommon to have patients with five or more conditions and on 10-17 medicines. So case reviews are quite frequent during the week. I have a set time for case reviews but it’s not just done in that time as we found it’s not enough.”
But she says her GP colleagues are fine with that – and at the end of the day the patients are also registered under a GP in the practice – which is not an issue for Murray who is happy to work as part of a team.
“Personally I love it and am grateful for it because when you start managing these really complex clients you have to have a good support network – you just have to. You can’t work in isolation or alone. You can still make those independent decisions as the nurse practitioner – that’s not a problem but you also have to have a collaborative supportive network around you of your medical colleagues. I don’t see how a NP working out in the community cannot have that relationship...to not develop those networks is actually isolating your patients. You can have your enrolled population as I do but you still have to have your medical colleagues and your networks.”
Prescribers have to be able to sleep well at night
Council proposals for community and specialist prescribing are given the thumbs up by Murray – particularly the plans to formalise training and competencies that can be ad hoc and inconsistent under standing orders.
“I think this is great for the public I really do,” says Murray. “And I salute those nurses who decide to go ahead with it.”
She believes committed specialist and community nurses will jump at the chance to prescribe but the competencies required could also make others look twice.
And that is how it should be believes Murray as moving from standing orders to prescribing “changes the ball game completely” as it shifts the accountability from the doctors shoulders to the nurses.
“It’s a huge weighty decision (becoming a prescriber) and it should be treated in that light. As I tell people you have to be able to sleep well at night when you make a decision – and if you can’t then I say definitely consult and refer on.
“That’s why knowing your boundaries and knowing your limitations is so important.
For those contemplating dipping their toes into prescribing Murray advises first seeking advice from a nurse who currently has prescribing authority. “We can provide a lot of insights into the reality of prescribing.”
And for those, like herself, working in rural settings and small town communities – be clear about setting your professional and personal boundaries.
“My home is my castle – it is my place of freedom. End of story. It is the only time out I have so I protect it ferociously.”
She’s on to her fourth unlisted home phone number “but I haven’t had to change that for at least …three years now!”
You can be passionate about your job – but it also pays to be pragmatic.