Taking a special approach

1 April 2013

Diabetes nursing managed to ‘jump the gun’ to RN prescribing with a successful demonstration site. Next off the starting blocks is expected to be respiratory nursing. FIONA CASSIE looks at some specialist areas and their likely prescribing ambitions.

Taking a deep breath
Asthma and chronic respiratory disease are amongst the most common treatment areas for nurse prescribers in the United Kingdom.

Respiratory nurse specialists were already discussing following their diabetes colleagues down a similar path to prescribing when news of the Nursing Council proposals started to filter through.

Last year, prescribing was top of the agenda of a respiratory nurse gathering at the Thoracic Society of Australia and New Zealand (TSANZ) annual meeting, where they were addressed by Helen Snell, the NP behind the diabetes nurse prescribing project.
What the respiratory nurses hold in common with their diabetes colleagues is a knowledge and skills framework (KSF) and they were looking at using their KSF to accredit the first respiratory prescribers when the Nursing Council consultation document proposed a different pathway.

Nicola Corna, chair of the respiratory section of the New Zealand Nurses Organisation, says it is now a matter of wait and see but the buzz from the TSANZ meeting and section feedback is that fellow respiratory nurse specialists are keen to have the chance to prescribe for their patients.

This is particularly relevant as at the moment, if respiratory nurse specialists give written directions around a patient’s medications while following their management care plan, they are technically seen as prescribing.

“If, for example, I have a patient who is asthmatic and I say to them that ‘okay when your peak flow gets to this point you need to use this medication in this way’, and if I write that down, and it’s not countersigned by a doctor, I’m seen as prescribing.”

“That’s a real barrier, a huge barrier to helping our patients,” says Corna, as it is nurses who see patients the most and are usually the ones who write the action plan.

But Corna for one also believes the Nursing Council will have to proceed with caution to get the training, formulary, and prescribing supervision right so it is consistent for all specialist nurse prescribers whether they are working in big metropolitan hospitals or small centres with just one nurse in the specialist field.

“So we have nurses who are safe prescribers, providing the best of care, and who are supported in their role and are not left feeling uncertain, insecure or unsafe in their practice.”

Keeping it in the family

For more than a decade, Family Planning nurses have been “supplying” the pill and treating uncomplicated infections for the vast majority of clients walking through the door.

This is all made possible through a clean and clear-cut training path for the association’s nurses and extensive use of standing orders that must be countersigned within four days.

The chance to step out from standing orders and have their skilled nursing workforce endorsed as prescribers would be welcomed, says Family Planning national nursing advisor Rose Stewart.

“Every day a doctor in every clinic spends time (countersigning standing orders) when they would otherwise be able to see clients…” says Stewart. “Many observe that it is unnecessary as the nurse’s clinical assessment and medication supply are done within clearly defined protocols and are appropriate.”

It also means nurses will carry full responsibility and doctors will not have to feel responsible for the nurses. Processes for getting medications to clients would also be less complex.

She agrees that possibly Family Planning has been ‘de facto’ pioneers of RN prescribing for many years, with nurses able to gain experience quite quickly because of the specialised area of practice. “It has enabled clients to access medication much more seamlessly as nurses do 75 per cent of all consultations and the volumes of medication supply are large.”

Stewart says Family Planning nurses have extensive training, including 60 hours one-on-one mentoring in the first weeks, seven days of courses over the first 12–18 months, and ongoing monitoring by chart audit and peer review.

She believes some of its nurses, who are doing or contemplating postgraduate study, may be eligible for endorsing as specialist prescribers but the majority of its nurses are likely to be endorsed as community prescribers.

“In a sense we would like them to be specialised nurse prescribers at community prescribing level.”

The organisation is also keen for its nurses to able to get community prescribing endorsement via a pathway specific to Family Planning and its context.

“Family planning nurses undergo a significant practicum during their training to level 2 and would need only a top up in terms of pharmacology and prescriber context. So the pathway to this lower level of prescribing should be as flexible as possible.”

Stewart says from its experience of preparing nurses to ‘supply’ medications the critical aspects are “in-practice mentoring and supervision, and the use of clear protocols nurses can refer to when providing medication”.

Diabetes a sweet success story

“I’m on a lot of medication and if people can get help other than from their GP, that will be great.”

That’s what Northland diabetes patient Geoff Sadler’s told Northland District Health Board on hearing that four Northland diabetes nurse specialists (DNS) are on the path to becoming designated prescribers.

“I have always had a great relationship with the diabetes nurses at the centre. If I get into trouble, I know I can ring her and she gives me advice”, adds Geoff Sadler.

“The registered nurse prescribing is a very positive thing alongside Care Plus and the care from my practice team”.

A dozen diabetes nurse specialists were the pioneers of registered nurse prescribing in 2011.

After a positive evaluation report for Health Workforce New Zealand the nurses have kept on prescribing and 16 more nurses, including the four Northland nurses, have been selected to follow as the project is rolled out nationwide including, for the first time, three nurses working in primary health organisations.

Helen Snell, the driving force behind the demonstration project, says she may be “naively optimistic” but she believes the success to date of the project bodes well for widening collaborative RN prescribing. Including primary health care with the 30 GPs who replied to the project evaluation survey all being comfortable and satisfied with the prescribing decisions made for patients under their care.

The one potential barrier Snell sees to widening RN prescribing to more settings – particularly primary health care – is finding the mentors and funding to support prescriber training. Under the demonstration project, the DNS prescribing practicum was carried out inhouse by the specialist services with no fees or tertiary education provider involved.

“You could argue that by doing that there wasn’t consistency of approach but we had a detailed practicum assessment document setting out requirements for case studies etc.”

With training dollars likely to be limited she had concerns if the prescribing practicum required to become a specialist nurse prescribers followed the model currently required for nurse practitioners, as the cost “could be prohibitive”. With potentially hundreds rather than dozens of nurses seeking practicums in the future, Snell believes there could be models explored for doing them in-house without too much of a burden to the employer organisation.