This site is intended for health professionals only

Nurse prescribing: promoting concordance

Ann Long
DPhil
Senior Lecturer
School of Nursing
University of Ulster
Jordanstown
E:ma.long@ulster.ac.uk

Rosario Baxter
MSc
Lecturer
School of Nursing
University of Ulster
Coleraine
Co Derry

Currently, all district nurses and health visitors in Northern Ireland have gone through a validated education and training programme in nurse prescribing held at the University of Ulster, and have recorded subsequently as prescribing nurses with the new Nursing and Midwifery Council. In tandem with nurse prescribing is the recognition that nurses do have the skills and competencies to carry out this role. As with all areas of practice, prescribing nurses use the Code of professional conduct as an ethic of care to guide their practice, and the Scope of professional practice to direct the procedures and practices they are confident and competent to carry out.(2,3) Prescribing nurses should therefore have the ability to prescribe safely, effectively and cost-effectively from the Nurses' Formulary. Indeed, the ability to prescribe should be seen within the context of individual professional responsibility and accountability, and reflect current expertise, experience and professionalism.

Competent practice, ethics and concordance in nurse prescribing
Health visitor and district nurse prescribers work within primary care teams, so it is essential that they have the skills and abilities to work in a collaborative and cooperative way with all members of the team, taking cognisance of their varying roles and expertise. All members of the primary care team must place the care and treatment of patients and their families first, and set achievable goals to meet assessed needs of all individuals in the practice population. In order to do this, open and honest communication is required by all members so that the team works in a person-valuing, harmonious and respectful manner. It is vital that any changes in the pattern of local service delivery should be introduced only after full consultation with patients and, whenever possible, in such a way as to increase rather than decrease patient choice. With the introduction of the new primary care groups, teams will need to consider carefully the best way of consulting patients on proposed changes. In relation to prescribing, effective communication includes providing feedback to the team, in particular to GPs, as they have overall responsibility for patient care.

Evidence-based healthcare implies that the best evidence has been evaluated, considered and communicated to patients to enable informed decisions to be made. This helps to ensure that potential problems are explored before treatment is prescribed.

Before prescribing drugs or appliances for patients it is essential that nurses carry out a full assessment of patients' physical, psychological, social and spiritual needs, including any additional treatment that has been prescribed previously or bought over the counter. A full risk assessment should also be carried out. Accurate assessment is essential and must be carried out in consultation with patients and their families/carers. Holistic assessment of the patient is a cyclical process that is carried out each time the nurse sees the patient.

For common disorders such as head lice or thrush, a practice protocol outlining the first treatment of choice can be helpful. The use of GP practice protocols means that all members of the team are working collaboratively and cooperatively. Following assessment of needs, nurses use their clinical judgment to make a working diagnosis of the patient's condition before prescribing the most appropriate treatment. Prescribing nurses use the Nurses' Formulary in conjunction with the latest edition of the BNF for details of all the products available. In consultation with the patient, the nurse designs and implements a nursing care plan. At this stage the nurse might decide to refer to the GP for further examination or to confirm the diagnosis and instigate further investigation.

Prescribing nurses must then write their prescription on a prescription pad bearing their own unique identifier number. Accountability for the prescription rests with the nurse who has issued the prescription or ordered the treatment.

Nurses will also take greater responsibility for the resources they allocate. All nurses are required to keep concurrent records that are unambiguous and legible. The Standards for records and record keeping outlines the requirement for nurses' records.(4) The record of the nurse's prescription should be entered into the patient-held record at the time of writing and should be entered into the GP practice patient record as soon as possible. Best practice suggests that this should be recorded within the time negotiated with local GPs and no later than 48 hours after the prescription has been written. To promote effective teamworking, open and transparent locally agreed statements of good practice need to be drawn up regarding the sharing of all relevant patient records. Guidelines on support systems, such as clinical supervision and continuing professional development for all team members, should also be drawn up. Taking these steps proactively helps clarify professional responsibilities, which ultimately lead to a strengthening of professional working relationships in primary care teams.

Nurses are in an ideal position to provide information on the prevention of common ailments, and health promotion has always been part of their role. Nurse prescribers must ensure that patients are informed of the scope and limits of nurse prescribing and how they can obtain other items necessary for their care. Nurses must provide patients with the necessary information required about the purpose of the treatment prescribed, when it will start acting, its benefits, contraindications and side-effects. Information should be provided on the storage, handling and disposal of treatments prescribed. This information may need to be repeated on more than one occasion when nurses evaluate their care and the patient's progress. Prescribed treatment frequently plays a key role in enabling people to achieve their optimum physical, psychological and social potential.

Concordance
Entering into a shared treatment contract devised between patient and prescriber is described as "concordance". This replaces and challenges the previous concept of compliance. Compliance meant that professionals made decisions about patients' health and wellbeing, usually defined by the professional to be in the patients' "best interests". In this relationship the patients' role was characterised as that of passive recipient in their own care. By contrast, concordance reflects the shift of power from professional to patient. It illustrates one index of an overarching philosophical shift away from medical paternalism to locating decision-making as a joint endeavour by both professional and patient. However, if the treatment regimen is complicated or the patient is bewildered, an adherence appliance that monitors dosage might be helpful. Patients need to be individually assessed so that the right adherence system matches patient needs.

Conventional wisdom suggests that patients need to respond to a whole variety of health promotion, medical advice and interventions in order to successfully negotiate treatment pathways, which can vary in duration from short-term to a lifelong commitment. This assumes that the value of a treatment is solely derived from its medical effectiveness, and denies the assertion that wellbeing is composed of more components than health alone. In one case a patient was prescribed medication for Parkinson's disease; over a long period of years she claimed that the drug made no difference to the condition, and expressed reluctance to continue the treatment, yet did so for fear of the negative consequences of discontinuation. Treatment that may include drug regimens where professional and client opinions digress in respect of the perceived value to the patient(5) creates relationship dissonance and dissatisfaction, which may threaten professional and patient autonomy. The right of the patient to object to the medication regimen inversely mirrors the perceived severity of the condition and the extent to which the condition is believed to respond to drug treatment. Factors such as the patient's age, knowledge and social or economic status may also impact upon the net value attached to respecting the right to refuse, or the professional obligation to provide treatment.(6)

Professionals are expected to "inform", "motivate" and "empower" patients so that success can be measured by the patient confidently "adhering" to the prescribed medication. Patients who persist in their unwillingness to take medication are likely to be labelled "difficult", and may therefore be a victim of limited autonomy, rationality or intellectual ability. Continued resistance towards taking medication may have profound consequences on the patient's health, as well as future client-professional relationships. The professional may conclude that the patient is not best placed to make decisions that affect his or her own life, thus prompting the professional to take on the mantle of paternalism, acting in the patients' "best interests".

The general direction of healthcare delivery is towards mutuality in practice(7,8) and increasing the weight attached to patient choice and responsibility in treatment choices.(9) It has been suggested that patients who have access to quality information, in a supportive relationship with the professional, can exercise accountability for their choices.(10) Limits to their freedom in making decisions (and thus accountability) are considered to be attenuated by personal factors such as the presence of fear or stress, and the possible (harmful) effects on others. An enhanced appreciation that patients' choices are coloured by previous experiences, personal values and ascribed benefits may point the way forward for respecting the involvement of clients in professional decision-making.

Searching the literature demonstrates that studies have been carried out that investigate comparisons between nurses' prescribing abilities and GPs' prescribing abilities. We do not consider such studies to be helpful in the promotion of respectful working relationships. Consciously or unconsciously nurses continue to reinforce the practice of defending themselves, and in this fruitless quest they end up trying to raise themselves up at the expense of putting another professional down. The findings of one study have demonstrated that being able to prescribe promotes closer and more trusting therapeutic alliances between nurses and patients, and improves adherence to treatment regimens.(11) Studies in the USA have shown that nonadherence to medication regimens by patients is directly attributable to the poverty of relationships formed during the initial encounter with health professionals.(12) Nurses are well placed to find out what patients, their families and carers think about the patient's illness and medication. They can also ascertain whether patients intend to take their medication and whether or not they will meet with the approval of their family or carers for doing so. Finally, nurses who have close and continuing contact with patients and who plan and carry through individual programmes of care are uniquely placed to make accurate assessments of patients' needs, prescribe treatments to meet patients' needs and take full responsibility for clinical decision-making, thus improving the quality of nursing care provided.

"Empowerment implies contributing to the shaping of society, rather than being subjected to the power of others. It goes beyond critical thought and includes a readiness to act with others to bring about the conditions that one has chosen through a process of collaborative, critical inquiry. Action [nurse prescribing] requires courage but it also requires a possession of knowledge and skills necessary to change a situation."(13)

References

  1. Department of Health. Report of the Advisory Group (Crown report). London: DOH; 1989.
  2. UKCC. Code of professional conduct. London: UKCC; 2002.
  3. UKCC. The scope of professional practice. London: UKCC; 1992.
  4. UKCC. Standards for records and record keeping. London,UKCC; 1993.
  5. White R, Tata P, Burns T. Mood, learned resourcefulness and perceptions of control in type 1 diabetes mellitus. J Psychosom Res 1996;40:205-12.
  6. Underwood MJ, Bailey JS. Coronary artery bypass should not be offered to smokers. BMJ 1993;306:1047-50.
  7. Williams B. Patient satisfaction: a valid concept? Soc Sci Med 1994;38:509-16.
  8. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (Or it takes at least two to tango.) Soc Sci Med 1997;44:681-92.
  9. Calnan N. Patients as consumers. In: Glynn JJ, Perrkins DA, editors. Managing health care. Challenges for the 90s. London: WB Saunders; 1995.p. 226-41.
  10. Yeo M. Toward an ethic of empowerment for health promotion. Health Promotion Int 1993;8:225-35.
  11. Gunn J. Nurses and prescriptive authority. Speciality Nursing Forum 1990;2:1-6.
  12. Keen J, Wolf R. Doctors and nurses dispute boundaries of medical domain. USA Today 1993;8 Dec.
  13. Berlak A, Berlak H. Teachers working with teachers to transform schools. In: Smyth J, editor. Educating teachers: changing the nature of pedagogical knowledge. Lewes: Falmer Press; 1987.