Decision making: the context of nurse prescribing

Implementation issues and barriers for assessing oral health in dependent patients after stroke: A qualitative study

OBJECTIVES

To explore implementation issues and potential barriers for assessing oral health in dependent post-stroke patients.

METHODS

Semi-structured interviews were conducted with a purposively identified sample of healthcare service providers who work in two National Health Service (NHS) Trusts in the north of England. Interviews were conducted until data saturation was achieved (n = 30). Data were analysed using the constant comparative method.

RESULTS

Six themes were drawn out in this study, which described potential barriers to assessing oral health in post-stroke patients, aspects of oral health that need assessment, streamlining the oral health assessment, input methods for oral health assessment, characteristics of assessors, and how oral care should be planned.

CONCLUSIONS

Assessment of oral health for post-stroke patients has been viewed as a complex task because of several identified barriers. Several suggestions have been proposed to overcome these barriers, aiming to enable more feasible and effective oral health assessments for post-stroke patients.

CLINICAL SIGNIFICANCE

The findings from this study have the potential to contribute to developing oral health measurement instruments that might be more successfully implemented and guide oral care planning for dependent patients after stroke.

Preparing pre-registration nurses to be 'prescriber ready': Aspirational or an achievable reality?

The Nursing and Midwifery Council (NMC), the professional body for U.K. registered nurses, midwives and nursing associates has recently proposed future nurses should be 'prescriber ready', in a move to ensure the nursing workforce can prescribe medicines soon after registration (NMC, 2018a). Considering this, the educational preparation requirements for future nurses requires consideration, particularly where it is incumbent on the University, or NMC Approved Educational Institution (AEI), to prepare nurses with sufficient knowledge and skills to enter an NMC approved non-medical prescribing programme from the point of registration. This paper explores the new NMC educational and practice standards for nurses and the potential infrastructures required of the AEI where there is a responsibility under the NMC to develop a new, more progressive generation of 'prescriber ready' nurse. Excitingly, Universities and nurse educators are now tasked with ensuring future nurses can safely demonstrate an amalgam of nursing care, fusing traditional nursing expertise with skills which once remained the exclusive responsibility of the doctor, thus creating a new generation of hybrid practitioners.

The leading edge in nursing research

The following is the opening address given by Professor Alison Tierney at the Royal College of Nursing's International Nursing Research Conference held at Heriot Watt University, Edinburgh, on April 3, 1998

Factors influencing nurse and pharmacist willingness to take or not take responsibility for non-medical prescribing

BACKGROUND

In the UK, the majority of non-medical prescribers (NMPs) are nurses or pharmacists working in community or primary care. However, little is known about what influences their decisions to prescribe, unlike with medical prescribing. It is also unclear whether the medical findings can be extrapolated, given their very different prescribing training.

OBJECTIVES

To explore the factors influencing whether nurse and pharmacist NMPs in community and primary care settings take responsibility for prescribing.

METHODS

Initially, 20 NMPs (15 nurses and 5 pharmacists) were purposively selected and interviewed using the critical incident technique about situations where they felt it was inappropriate for them to take responsibility for prescribing or where they were uneasy about doing so. In addition, more general factors influencing their decision to take or not take prescribing responsibility were discussed. Subsequently, the themes from the interview analysis were validated in three focus groups with a total of 10 nurse NMPs. All data were analyzed using a constant comparison approach.

RESULTS

Fifty-two critical incidents were recorded--12 from pharmacist NMPs and 40 from nurse NMPs. Participants experienced situations where they were reluctant to accept responsibility for prescribing. Perceptions of competency, role and risk influenced their decision to prescribe. Workarounds such as delaying the prescribing decision or refer the patient to a doctor were used.

CONCLUSIONS

For NMPs to feel more confident about taking responsibility for prescribing, these issues of competency, role and perceived risk need to be addressed. Roles of NMPs must be clear to colleagues, doctors and patients. Training and support must be provided to enable professional development and increasing competence of NMPs.

Clinical credibility and trustworthiness are key characteristics used to identify colleagues from whom to seek information

AIMS AND OBJECTIVES

To explore the use of information by nurses making decisions in clinically uncertain situations in one aspect of critical care nursing practice (enteral feeding). In this paper, we report the characteristics, which participants identified as important, of the people from whom they sought information for the purpose of making clinical decisions.

BACKGROUND

Registered nurses have a plethora of information sources available to assist them in making clinical decisions. Identifying and selecting the best information to support these decisions can be difficult and is influenced by factors such as accessibility, usefulness and variations in quality of the information.

DESIGN

An instrumental case study design using multiple case study analysis.

METHOD

Twenty-two critical care nurses from two intensive care units contributed to the data through multiple methods of data collection including concurrent verbal protocols (think aloud), retrospective probing and focus group interviews.

RESULTS

Nurses preferentially used colleagues as a source of information when faced with uncertainty about their clinical practice. Most participants placed greater emphasis on evaluating the individual providing the information rather than on evaluating the information itself. Key features used for identifying an individual as a source of information included experience, clinical role, trust and approachability.

CONCLUSION

Establishing clearly what clinical credibility means, and to what extent trustworthiness and expertise play a role in the establishment of credibility, is an important debate for nursing. We need to carefully consider what defines the construct of clinical credibility and how this aligns with the concept of clinical currency, to allow clinicians to determine in others the characteristics associated with clinical credibility to access quality information through social interaction.

RELEVANCE TO CLINICAL PRACTICE

Processes to focus on determining the quality of information obtained from colleagues should be emphasised. What these processes are and how they could be implemented into clinical practice remains unknown and is highlighted as an area for future research.

Nurse prescribing from the community nurse's perspective

Background

Since 1994, district nurses and health visitors in the United Kingdom have been able to prescribe from a limited formulary. Items which are prescribed by these nurses are wound care products, incontinence appliances and medicinal preparations such as paracetamol and emollients. There is a planned expansion of prescribing by nurses, in terms of both the range of products and drugs that are prescribable and the types of nurses eligible for training for this new role.

Objective

To investigate patterns of nurse prescribing among community nurses in three primary care trusts in the United Kingdom.

Methods

Postal survey to 164 community nurses who were qualified to prescribe. Responses were received from 129 (79 per cent) with 35 nurses identifying themselves as not prescribing and excluded from the sample; 93 (72 per cent) of the questionnaires were entered on a database for analysis.

Key findings

Prescribing costs for district nurses ranged from £7.65 to £18,053 (median £2,023.64) and for health visitors from £0.73 to £2,556 (median £42.77) for a 12-month period. Nineteen per cent (n=28) of community nurses had decided not to prescribe even though they were trained to do so. Infrastructures and mechanisms to support nurses with nurse prescribing have been slow to emerge. Nurses perceived that their ability to prescribe was benefiting their patients and that they were providing better care. Community nurses cautiously welcomed the proposed extension of nurse prescribing.

Conclusions

Nurse prescribing has allowed community nurses more autonomy in managing a patient's total care. Our findings suggest that around one-quarter of nurses qualified to prescribe are not doing so. With the imminent extension of nurse prescribing for other nurses, action is needed by primary care trusts to put structures in place to ensure that nurses take on board this extension and challenge to their role.

Exploring understanding of the term nursing assessment: a mixed method review of the literature

BACKGROUND

Much skilled nursing practice is described by words that at face value appear low-tech and self-explanatory. Despite being intrinsic to practice, the term "nursing assessment" has few operational definitions. Evidence-based practice and the quality agenda makes it imperative that this term is well understood.

OBJECTIVES

To contribute to the evidence base and facilitate a greater understanding of assessment of patients as carried out by nurses through exploring the research question: How is the term "nursing assessment" used in the current health care literature?

DESIGN

The review process, synthesised from the work of Greenhalgh et al. (2005), Clancy (2002), Egger et al. (2001), identified and assessed the quality of articles, text books, the grey literature, policy documents and databases. Glaser's Grounded Theory (GT) method was utilised to analyse the concept of "assessment" as exemplified within the included studies.

METHODS

The focus for this mixed-method review is the health care literature between 1990 and 2005. Studies were identified, screened and assessed for methodological quality and data were extracted and recorded. Analysis of the included studies was facilitated using a GT approach. Possible tensions when using a mixed-method research design are acknowledged and briefly discussed.

RESULTS

Of the 32,602 instances initially identified, 329 articles, policy documents and book extracts were closely read and after further screening, 120 articles and 12 policy documents and book extracts were analysed. Seven overlapping categories were identified, with "judicial" or "judgement making" identified as the core category.

CONCLUSIONS

Hierarchies of nursing practice, government policies and inter-professional agendas cause barriers to meaningful assessment. Informal and formal assessments and screening processes are often conflated, resulting in confusion regarding the scope and nature of the process. Differences between the rhetoric of placing the patient at the heart of the assessment process and practice have been identified.

Pharmacists' and mentors' views on the introduction of pharmacist supplementary prescribing: a qualitative evaluation of views and context

Objective Supplementary prescribing has been a major policy initiative in the UK, which has seen pharmacists and nurses assume greater responsibility for prescribing in collaboration with doctors. This study explored the views and professional context of pharmacists and physicians (who acted as their training mentors), prior to the start of supplementary prescribing training.

Setting Primary and secondary healthcare settings in Northern Ireland.

Method All pharmacists (n = 63) from the first four cohorts enrolled for supplementary prescribing training in Northern Ireland were invited to participate in a series of focus groups, while mentors (n = 54) were asked to participate in face-to-face semi-structured interviews; the research took place between September 2003 and April 2005. All discussions/interviews were audiotaped and transcribed, and analysed using constant comparison.

Key findings Nine pharmacist focus groups were convened (number per group ranging from 4 to 8; total n = 47) and 35 semi-structured interviews with mentors were conducted. The four main themes that emerged were internal drivers, benefits and concerns, relationships, and beyond the current professional comfort zone. Supplementary prescribing was broadly welcomed by both professional groups and was anticipated to produce improvements in patient care and interprofessional relationships, but there were some concerns about loss of diversity, deskilling of junior doctors, safety and professional encroachment. Caution was expressed with regard to a further extension of prescribing rights, particularly in relation to the role of pharmacists in diagnosis and independent prescribing decision making.

Conclusion Although supplementary prescribing was viewed positively, these findings should be considered in the light of more recent developments in prescribing rights for other health professionals, including pharmacists.

Views on nurse prescribing: a survey of community mental health nurses in the Republic of Ireland

A nurse prescribing scheme has recently been implemented within the Republic of Ireland. This paper reports on the views of community mental health nurses on nurse prescribing just prior to the implementation of the scheme. Data were gathered through a 13-item questionnaire administered to 103 members of the Association of Community Mental Health Nurses in Ireland. Results indicated a distinct difference of view between male and female community mental health nurses, with female nurses having greater reservations towards the desirability of nurse prescribing in relation to educational preparation and impact on professional relationships. Overall, only 17% of respondents favoured being supervised in their prescribing practice by their consultant psychiatrist. The paper concludes that there is ambivalence towards prescribing in this important group of nurses which may need to be taken into account if nurse prescribing is to be successfully implemented within the Irish mental health service context.

Nurse supplementary prescribing for patients with diabetes: a national questionnaire survey

AIMS AND OBJECTIVES

To examine the prescribing practices of nurse supplementary prescribing in diabetes.

BACKGROUND

Nurses in several roles are involved in the management of medicines for patients with diabetes. Nurse prescribing should help optimise these roles. Nurses in the UK have virtually the same independent prescribing rights as doctors. There is little or no evidence on the extent to which nurse supplementary prescribing is used, or the impact and activity of nurse supplementary prescribing for patients with diabetes.

DESIGN

Survey.

METHOD

A random sample of 214 nurse supplementary prescribers self-completed a written questionnaire.

RESULTS

The majority of nurses held an academic qualification at degree level or higher, had a wealth of clinical experience, worked full-time, were based in primary care and worked in general practice. The majority of nurses prescribed between one and five items a week. Oral anti-diabetic drugs, hypertension and lipid-regulating drugs and insulins were the products most often prescribed. Over 85% had undertaken specialist training in diabetes prior to undertaking the prescribing programme.

CONCLUSION

Supplementary prescribing provides a practical and useful framework within which to prescribe medicines for patients with diabetes and its associated complications. Specialist diabetes training is a necessary prerequisite for nurses prescribing in this area. It is evident that there is still a place for supplementary prescribing.

IMPLICATIONS FOR CLINICAL PRACTICE

* Recent legislative changes mean that nurses can now independently prescribe practically any drug. * Nurses in general practice appear to prescribe most frequently as a nurse supplementary prescriber for patients with diabetes. * Nurse supplementary prescribers are likely to use this mode of prescribing to deliver medicines to patients with diabetes. * Over two-thirds prescribe for common but serious complications of diabetes, e.g. hypertension, hyperlipidaemia and cardiovascular disease.

Why do district nurse prescribers alter their prescribing patterns?

This paper describes how district nurses decide what products to start prescribing and explores the reasons why prescribing patterns change. It is based on semi-structured interviews with fourteen nurses from one primary care trust. The first products prescribed immediately following qualification depended on the route taken to becoming a prescriber. These were either the same products they had been using before qualifying as a prescriber or if prescribing was included with their district nurse training then it was the same products that their mentor prescribed. The two drivers for changes in prescribing patterns were patients, whose current therapy was ineffective, and products, where patients were selected to try new products on. Representatives from the pharmaceutical industry and fellow nurses had the greatest influence on product selection for those prescribers that changed their prescribing. The nurse's own experience had the greatest impact on the decision to continue prescribing a new product.

What factors influence case managers' resource allocation decisions? A systematic review of the literature

OBJECTIVE

Case managers' decisions directly affect the amount and type of services individual clients receive, as well as overall home care program available resources. We know little about the resource allocation decision-making processes of case managers. The question guiding this review was, "What factors influence case managers' resource allocation decisions in home care?''

METHODS

The authors did a systematic literature review to answer the above question. After assessing the articles for inclusion, they assessed the quality (internal validity) of each included study. They described the characteristics of the studies and provided a synthesis of the findings of the primary studies.

RESULTS

Five qualitative and 6 quantitative articles met the inclusion criteria for this review. The findings of these studies are equivocal. Despite this, the authors were able to create a preliminary taxonomy of the factors that influence case manager resource allocation decisions. Despite evidence-based decision making receiving so much attention in contemporary health care literature, the authors found a near absence of reference to research use in the context of case manager decision making.

CONCLUSIONS

Currently, there are relatively few studies in the literature on the factors that influence, and how they are used in, case manager resource allocation decisions. Studies are often lacking in terms of conceptual clarity and theoretical framing. They are often not guided by theoretical frameworks and are not situated within the larger field of decision making or even within the clinical decision-making literature. These issues are impeding progress in this area.

Framework for teaching pharmacology to prepare graduate nurse for prescribing in New Zealand

The place of nurse prescribing and the preparation for this role is an educational challenge that has been heavily debated in New Zealand and overseas for the past 10 years. Nurse prescribing is relatively new in New Zealand and is related to the expanding roles and opportunities for nurses in health care. Opposition to nurse prescribing in New Zealand has been marked and often this has been linked to concerns over patient safety with the implication that nurses could not be adequately prepared for safe prescribing. The educational framework used to teach pharmacology to nurses by one university in New Zealand is presented, along with early findings on the effectiveness of this approach. Further research is required to confirm that nurse prescribers in New Zealand are well prepared and able to utilise effective decision-making processes for safe prescribing.

Nurse prescribing: Reflections on safety in practice

This qualitative study explores how recently qualified nurse prescribers describe, and rate, the safety of their prescribing. Internationally, the costs of drug errors are enormous and they can have serious implications for staff and patients. Nurses are now undertaking extended prescribing practice throughout the UK. Nurse prescribers work across different work settings and although safe prescribing is a priority in all of them, it is essential to ascertain the conditions that foster the highest levels of safety and how nurses can be supported in practice. Thirty-one nurses form the West Midlands area of England agreed to participate in an in-depth interview which sought to elicit their responses to various aspects of their prescribing work. They came from a variety of specialities and from hospital, community and general practice backgrounds. On completion of their training nurses were acutely aware of the responsibility that prescribing imposed on them. Although this awareness was thought to encourage caution and safety, it may also account for the fact that 26% of the nurses (n=8) had not prescribed since qualifying. Nurses felt that the multidisciplinary team had a vital role to play in supporting their prescribing practice as did collaborative working. It is concluded that those working in specialty areas that are less well-defined in terms of scope of practice (e.g. older adult nursing and learning disability) would benefit in particular from ongoing mentoring relationships with experienced prescribers and the development of individual formularies.

Supporting practice teachers to identify failing students

The subject of identifying and supporting failing students in community nursing education programmes has been largely overlooked in the literature, yet is of great concern to practice teachers. This article discusses the views on the topic of a group of practice teachers in the light of existing, related research and proposes a number of indicators for good practice. It is suggested that of central importance is the need for higher education institutions and practice teachers to work together in identifying students causing concern at an early stage in their studies, based on both objective and subjective observations, and to have in place documented procedures to be followed when such situations arise.

A review of clinical decision making: models and current research

AIMS AND OBJECTIVES

The aim of this paper was to review the current literature clinical decision-making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information-processing model, the intuitive-humanist model and the clinical decision-making model.

BACKGROUND

Clinical decision making is a unique process that involves the interplay between knowledge of pre-existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information-processing model and the intuitive-humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information-processing model but also examines patient specific elements that are necessary for cue and pattern recognition.

DESIGN

Literature review.

METHODS

Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005.

RESULTS

The characteristics of the three models of decision making were identified and the related research discussed.

CONCLUSIONS

Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision-making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed.

RELEVANCE TO CLINICAL PRACTICE

It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing-related problems. It is suggested that O'Neill's clinical decision-making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.

Why don't trained community nurse prescribers prescribe?

AIMS AND OBJECTIVES

(i) To identify barriers that could either prevent community nurses from prescribing altogether or reduce the number of times that a nurse might prescribe. (ii) To determine how wide spread the barriers identified above were.

BACKGROUND

Many community nurses who are trained to prescribe are either not prescribing at all or not routinely doing so.

METHOD

(i) Qualitative semi-structured interviews with nurses prescribers and Trust prescribing leads. (ii) Postal questionnaires sent to the nurse prescribing leads in each Primary Care Trust across three strategic health authorities in England.

RESULTS

Several barriers were identified in this study. Those that (i) prevented prescribing included roles with no patient contact, prescription pads not issued, opposition from general practitioners and lack of confidence; (ii) prevented some prescribing included lack of time in clinics, inability to prescribe for patients registered with another Trust, security concerns, lack of access to patient medical records and the use of alternative methods of supply; (iii) made prescribing more difficult included keeping records, informing general practitioner of items prescribed, delivering prescribed items to housebound patients and situations requiring items from more than one prescriber.

CONCLUSION

Many barriers have been identified that have the potential to reduce the impact of nurse prescribing on patient care. Trusts should monitor the prescribing of their nurse prescribers, target appropriate support and encouragement to address problems with prescriber confidence, develop strategies to integrate their nurse prescribers into the healthcare team to improve access to patient's medical notes, and improve the efficiency of the prescribing process.

RELEVANCE TO CLINICAL PRACTICE

There is a danger that the anticipated benefits to patient care resulting from the introduction of nurse prescribing may not materialize if the barriers identified in this study are not addressed.

Diagnostic practise in nursing: A critical review of the literature

The purpose of this article is to critically review and synthesize the literature related to the general concepts and the process of diagnosing the client's condition, and the possible variables which influence diagnostic practise in nursing. It is suggested that statistical theories are capable of capturing the diagnostic process and offer an effective means to predict diagnostic decisions. Studies underpinned by information-processing theory argue that diagnosing a patient's condition follows a hypothetico-deductive model that consists of specific stages. Those who hold a phenomenological perspective remark that there is yet another form of diagnostic practise: intuitive reasoning, which plays an important role in diagnosing the patient's clinical condition. Other related studies suggest that diagnostic practise is contingent on some personal, psychosocial, and structural variables. Regrettably, these studies offer no conclusive explanation to delineate diagnostic practise in nursing. Based on the literature reviewed, a conceptual framework is suggested to help articulate the underlying structures and processes of diagnostic practise in nursing.

Extended nurse prescribing: improving care for older people

This article examines the benefits to older patients in a hospital setting, including assessment, diagnosis and treatment by a nurse who is competent in the field and has in-depth personal and professional knowledge of that person. It explores how this approach promotes individual high quality care through a patient-centred focus and empowerment while supporting the Department of Health and Scottish Executive Health Department's agenda for service redesign. It also explores how expansion of the extended independent nurse prescriber's formulary will not compromise patient safety. It recommends that nurses practicing in non-acute care areas consider developing as extended independent nurse prescribers to raise standards of patient-centred care delivered to older people in hospital. The Nurse Prescribers' Extended Formulary (British Medical Association and Royal Pharmaceutical Society of Great Britain in association with Community Practitioners, Health Visitors' Association and Royal College of Nursing, 2003) is referred to throughout this paper as the nurses' formulary, nurse prescribers' formulary or nurse prescribers' extended formulary.

Integrated undergraduate nursing curriculum for pharmacology

Undergraduate pharmacology education for nurses has tended to follow one of two broad approaches, either specific courses in pharmacology or an integrated approach, where the pharmacology content is blended with other content. The School of Nursing at the University of Auckland selected an integrated approach to pharmacology education for nurses aligned with constructivist learning theory. The weaving of pharmacology through the three-year undergraduate curriculum is described, showing the development of a pharmacology curricula thread. The significance of supporting curricula content in areas such as communication skills, law and ethics, as well as sound biological science and physiology knowledge are highlighted. A sound understanding of pharmacology knowledge does not develop in isolation. Rather pharmacology education in the undergraduate nurse is the beginning of developing pharmacological reasoning and providing the skills for life-long learning in this ever changing subject.

Nurse practitioner and practice nurses' use of research information in clinical decision making: findings from an exploratory study

BACKGROUND

There is a lack of evidence regarding the kinds of decisions made by primary care nurses and the information sources they use in clinical decision making.

OBJECTIVE

To describe the decisions made by nurses working in general practice and the sources of information they use to underpin those decisions.

METHODS

Qualitative methods (interviews, observation, documentary analysis) were used to collect data on the clinical decision making and information seeking behaviour of a purposive sample of 29 practice nurses and four nurse practitioners from general practices in the North of England. Data were collected November 2001-September 2002.

RESULTS

A seven-fold typology captured the types of decisions the nurses made on a daily basis concerning assessment, diagnosis, intervention, referral, communication, service delivery and organization (SDO) and information seeking. Faced with clinical uncertainty, the majority of the nurses in the study relied on personal experience, or obtained advice and information from GP or other colleagues. These 'human sources' of information were overwhelmingly preferred to text or on-line resources. Despite encounters with evidence-based resources through continuing professional development, the nurses rarely used them to seek answers to routine clinical questions.

CONCLUSION

The decisions of the nurses in the study were mainly concerned with undifferentiated diagnosis and treatment, in the context of acute conditions and chronic disease management. 'Human sources' of information were preferred to any other; however, we do not know whether information obtained from colleagues is based on research.

Variability in the clinical practice of maintaining the patency of peripheral intravenous catheters

OBJECTIVE

To establish variations in clinical practice associated with maintaining the patency of peripheral intravenous catheters (PIC) and to determine to what extent such clinical practice falls within the limits of the available scientific evidence, based on a random sample Spanish public hospitals.

METHODS

A cross-sectional, descriptive study was carried out in non-psychiatric public hospitals and their associated medical and surgical units. Cluster (hospitals), stratified (hospital size), and single level (all units) sampling was applied. A questionnaire was mailed to all of the units involved.

RESULTS

A sample of 341 valid questionnaires was analysed (response rate 54.5%). Only one praxis-modality was carried out in the majority of units. Intermittent flushing and heparin saline versus normal saline was the most frequent modality employed, over those of continuous flushing and non-heparinised saline. There was a high degree of variation in the quantity of heparin administered: 81.7% when flushing was carried out with heparinised saline and 48.2% when it was conducted with concentrated heparin. About 40% of this variation was associated with the hospital in question, rather than with the unit. The clinical practice fell within the limits of available scientific evidence in fewer than half of the units studied.

CONCLUSIONS

There was a high degree of variability in the practice of maintaining PIC patency. A significant part of this variation was attributable to the hospital in which the practice was carried out. Moreover, most of this practice was carried out beyond the limits of available scientific evidence.

Cognitive Continuum Theory in nursing decision-making

AIM

The purpose of this paper is to analyse and evaluate Cognitive Continuum Theory and to provide evidence for its relevance to nurses' decision-making.

BACKGROUND

It is critical that theories used in nursing are evaluated to provide an understanding of their aims, concepts and usefulness. With the advent of evidence-based care, theories on decision-making have acquired increased significance.

METHOD

The criteria identified by Fawcett's framework has been used to analyse and evaluate Hammond's Cognitive Continuum Theory. Findings. There is empirical evidence to support many of the concepts and propositions of Cognitive Continuum Theory. The theory has been applied to the decision-making process of many professionals, including medical practitioners and nurses. Existing evidence suggests that Cognitive Continuum Theory can provide the framework to explain decision-making in nursing.

CONCLUSION

Cognitive Continuum Theory has the potential to make major contributions towards understanding the decision-making process of nurses in the clinical environment. Knowledge of the theory in nursing practice has become crucial.

Nurse prescribers' experiences of prescribing

BACKGROUND

Nurse prescribing has advanced rapidly over the previous decade and is clearly on the agenda for the future. Previous research considers nurse prescribing from the patient's perspective, the medical professions' stance and the legal and ethical implications. However, there is a paucity of literature that explores the experiences of nurse prescribers' within their current role. These experiences need investigating to ensure nurse prescribing is able to advance in ways that provide benefit to nurses and thus provides the impetus for the study.

AIM

To explore and review nurse prescribers' experiences of prescribing.

DESIGN METHODS

A purposeful sample of seven nurse prescribers currently prescribing within a West Midlands Community Trust underwent minimally structured interviews in this qualitative study. Transcribed interviews were analyzed using thematic analysis.

FINDINGS

Four themes were generated from analysis of the interviews, 'patient centred care', 'benefits of nurse prescribing', 'support and role satisfaction' and finally 'prescribing difficulties'.

CONCLUSIONS

Nurse prescribers' perceive prescribing as a predominantly positive experience, frequently asserting the advantages that prescribing saves the patient and nurse time, is more convenient for the patient and increases the nurses' autonomy and role satisfaction. However, negative experiences of restrictions to practice as a result of nurse prescribers' formulary limitations and duplication of documentation were also described.

RELEVANCE TO CLINICAL PRACTICE

Nurse prescribing is a rapidly evolving area of practice with the potential to advance nursing roles. This research aims to provide an insight into the experiences of current nurse prescribers that may then be disseminated and applied to future practice.

Decision-making models used by 'graduate nurses' managing patients' medications

BACKGROUND

Nurses in a graduate programme in Australia are those who are in the first year of clinical practice following completion of a 3-year undergraduate nursing degree. When working in an acute care setting, they need to make complex and ever-changing decisions about patients' medications in a clinical environment affected by multifaceted, contextual issues. It is important that comprehensive information about graduate nurses' decision-making processes and the contextual influences affecting these processes are obtained in order to prepare them to meet patients' needs.

AIM

The purpose of this paper is to report a study that sought to answer the following questions: What are the barriers that impede graduate nurses' clinical judgement in their medication management activities? How do contextual issues impact on graduate nurses' medication management activities? The decision-making models considered were: hypothetico-deductive reasoning, pattern recognition and intuition.

METHODS

Twelve graduate nurses who were involved in direct patient care in medical and surgical wards of a metropolitan teaching hospital located in Melbourne, Australia participated in the study. Participant observations were conducted with the graduate nurses during a 2-hour period during the times when medications were being administered to patients. Graduate nurses were also interviewed to elicit further information about how they made decisions about patients' medications.

RESULTS

The most common model used was hypothetico-deductive reasoning, followed by pattern recognition and then intuition. The study showed that graduate nurses had a good understanding of how physical assessment affected whether medications should be administered or not. When negotiating treatment options, graduate nurses readily consulted with more experienced nursing colleagues and doctors.

STUDY LIMITATIONS

It is possible that graduate nurses demonstrated a raised awareness of managing patients' medications as a consequence of being observed.

CONCLUSIONS

The complexity of the clinical practice setting means that graduate nurses need to adapt rapidly to make sound and appropriate decisions about patient care.

Nurse practitioner education: a research-based curriculum structure

BACKGROUND

The process and content of nurse practitioner educational preparation has received scant research attention, despite increasing interest in and investigations into nurse practitioner services in Australia and internationally.

AIMS

The aim of this paper is to report a study investigating the educational process and content required for nurse practitioner preparation.

METHODS

A trial of practice was conducted with four nurse practitioner candidates over a 12-month period. The candidates practised in different specialities, giving rise to four models of the nurse practitioner role. The trial had multiple aims related to the role and scope of practice of the nurse practitioner. An action learning model was used, in which participating nurse practitioner candidates 'worked-into-the-role' of extended practice and learned from experience through clinical mentoring, reflection and action. Data collection methods centred on transcripts from group work activities related to a collaborative engagement with and reflections on clinical practice. This resulted in the collaborative production of data to inform a research-based nurse practitioner curriculum structure.

FINDINGS

The findings relate to the content and learning process required for nurse practitioner education and are described in terms of three broad areas of study: clinical practice, clinical sciences and nursing studies.

CONCLUSIONS

A curriculum structure that describes content and process for nurse practitioner education was developed from the findings. A further outcome of this trial was confirmation of importance of the clinical environment for nurse practitioner education. Inherent in this aspect of clinical learning is the role of a committed clinical mentor who can facilitate purposeful learning.

Benefits and challenges of nurse prescribing

BACKGROUND

Since 1999, all health visitors and district nurses in the United Kingdom (UK) have received additional education to permit their registration as independent prescribers from a limited list of medicinal products. Little research has investigated how more than 20 000 health visitor and district nurse prescribers have implemented their new role since the evaluation of the pilot sites.

AIMS

The aims of the study were to describe prescribing practices of health visitors and district nurses, the factors (contextual and professional) which enable and facilitate nurse prescribing, and views about the Nurse Prescribers' Formulary.

METHOD

A mail survey was conducted of all health visitors and district nurses working in three trusts in southern England. A 74% response rate was achieved (n = 91).

FINDINGS

Most respondents prescribed less than three times a week, with district nurses prescribing significantly more than health visitors (P </= 0.001). Over two-thirds of the sample found nurse prescribing at least moderately helpful to their professional role and over four-fifths reported that they were more than moderately confident nurse prescribers. A range of information sources was identified as helpful, regarding both new products and for continuing educational needs. Over two-thirds reported that the current Nurse Prescribers' Formulary did not cover their prescribing needs, and a number of factors were identified as hindering prescribing. Most respondents said that their general practitioner/primary care team was at least moderately supportive of their prescribing role.

LIMITATIONS

The survey was conducted in three primary care trusts in southern England, which may be unrepresentative of trusts elsewhere in UK.

CONCLUSIONS

The level of reported prescribing by health visitors and district nurses in this study indicates that they are not acting as substitute prescribers for general practitioners of the products in the limited formulary. Implementation of a major role change such as nurse prescribing requires a number of conditions, including adequate education/preparation, a formulary that meets practitioners' needs, and acceptance by the practitioners themselves.

Nurses' perceptions of their pharmacology educational needs

BACKGROUND

Pharmacology education in nursing has become increasingly important as nurses' roles in administering, prescribing and educating patients about their medications have grown. Some authors have expressed concern at the lack of science teaching in nurse education, and others have suggested that there is a theory-practice gap in this area of the curriculum.

AIM

This paper reports a study to explore nurses' pharmacology education needs by identifying nursing roles that require pharmacology knowledge, and nurses' preparation for practice from preregistration pharmacology education.

METHOD

A qualitative approach was used to collect data from a purposive sample of 10 qualified nurses from an emergency admissions unit in a city in the north of England. Semi-structured interviews were transcribed verbatim and categorized using Burnard's 14 stages.

FINDINGS

This study revealed a limited understanding of the subject, and dissatisfaction with the teaching of pharmacology, with resulting anxiety on qualifying. Nursing roles identified as requiring pharmacology knowledge included drug administration, patient assessment, nurse prescribing, and patient medication education.

CONCLUSION

The findings suggest that, although nurses have a limited understanding of pharmacology, they recognize the need for pharmacology knowledge in practice. Improved pharmacology teaching might increase nurses' confidence in performing drug administration, patient education, and nurse prescribing, and decrease anxieties related to these roles.

Decision making in Greek and English registered nurses in coronary care units

Clinical decision-making is an integral component of the role of the professional nurse. The aim of the study was to identify the quality of decision making of Greek and English coronary care nurses during the acute and recovery phases post-myocardial infarction (MI), and determine factors that best predict clinical decision-making in these two discrete groups of nurses. By identifying best practice from standard textbooks and expert practitioners, Clinical Decision-Making cards were developed and employed to explore nurse decision-making. A questionnaire (influencing factor questionnaire-IFQ) was also administered to determine which factors predicted quality nurse decision-making in the acute and recovery phase of post-MI patient care. The results showed that nurses in England made better quality clinical decisions in the recovery phase of MI than the Greek counterparts (p<0.001). Variables were identified which best-predicted decision-making. Interestingly, the main finding of this study was that English nurses had greater autonomy in the recovery phase and therefore made more clinical decisions concerning the patient psychosocial recovery than Greek nurses. Nurses perceived clinical experience as the strongest factor influencing decision-making.

Exploring views on Swedish district nurses' prescribing--a focus group study in primary health care

Since 1994 district nurses (DNs) in Sweden have been permitted to prescribe drugs from a limited list. This reform has met severe resistance from doctors and the opinions of general practitioners (GPs) and DNs have differed in many aspects. The aim of this study was to gain deeper understanding of the different opinions about DNs' prescribing and to explore the impact of the reform on primary care. Six focus group interviews were conducted, four with DNs and two with GPs. Data analysis revealed six categories, which were condensed into two dimensions. The dimensions were individual prerequisites, with the categories responsibility and knowledge, and organizational prerequisites, with the categories distribution of work, climate of co-operation, resistance and economic considerations. District nurses were very positive towards prescribing and had gained new knowledge through the compulsory training course and via discussions with pharmacists. Because of the responsibility required for prescribing, some nurses had introduced systems for self-monitoring. Prescribing was seen as a natural part of the nursing process. All interviewees could describe periods of resistance against the reform, and the head of the health centre was a key person for attitudes at the workplace. The DNs found the nurse prescribing reform very positive. They experienced a strengthening of professionalism and also thought that the reform was a natural development. Negative attitudes and opinions offset the positive feelings. The resistance that had appeared in the beginning had now turned into silent acceptance.

The information sources used by community nurse prescribers

A purposive sample of 22 community nurse prescribers and five prescribing leads were interviewed to determine how nurses both access and assess the reliability of pharmacological information. Prescribers used both printed material and other professionals to obtain pharmacological information. The most commonly mentioned sources of printed material were journals and the British National Formulary. Other people that nurses obtained information from included pharmaceutical company representatives, community pharmacists, nurse specialists, colleagues, and GPs. Nurses described the attributes that they associated with reliable information (previous vetting, up-to-date and used by other healthcare professionals) and unreliable information (produced by those with a vested interest). Much of the pharmacological information supporting prescribers is aimed at doctors and may not be accessible for nurse prescribers. Organizations seeking to influence evidence-based practice should consider the method of communication in addition to the message.

Preparing CNSs for prescriptive authority: Winona State University Model Course

Medical-surgical clinical nurse specialists (CNSs) have always been involved in treating disease-based and nondisease-based health problems. Recently, expanding state nurse practice acts have allowed medical-surgical CNSs to add pharmacologic agents to their arsenal of advanced practice interventions to best manage their patients' complex healthcare needs. This article discusses the history of prescriptive authority for medical-surgical CNSs, describes a new university program for preparing CNSs for prescriptive authority, summarizes interview responses of 4 students who have completed the university program, and highlights implications for practice and education. The university program includes coursework and clinical training and integrates distance-education strategies to reach students with diverse geographic and scheduling challenges. Themes from the 4 student interviews are positive and support CNSs having prescriptive authority. Facilitators and barriers to actualizing CNS prescriptive authority, implications for educational programs, and issues surrounding distance-education and clinical training are highlighted.

Managing adverse drug reactions: an orphan task

BACKGROUND

Nurse prescribing initiatives have potential to impact on medication management for long-term conditions. Over time, the adverse effects of medications become increasingly onerous. This 'side-effect burden' is particularly heavy for users of antipsychotic medication. Although consensus exists that strategies are needed to alleviate these problems, currently, they are not clearly the responsibility of any one professional group.

AIM

This paper explores the introduction of nurse-administered evaluation checklists, in relation to nurse prescribing initiatives and division of professional responsibilities for medication management.

METHODS

This was an observation study, with a quasi-experimental comparator group design, undertaken with clients receiving long-term antipsychotic medication. In both intervention and comparator groups, before and after introduction of evaluation checklists in the intervention group, 20 nurse-client interactions were observed. Problems actioned by the nurses, with and without the checklists, were compared. Stakeholders' views were sought concurrently.

FINDINGS

Implementation of evaluation checklists increased the numbers of adverse effects detected and actioned by nurses. They also served to apportion aspects of medication management between nurses and medical prescribers. Most actions taken by nurses to alleviate adverse effects concerned clients' physical health and advice on health-promotion. However, the nurses' interventions would have been more effective had they been able to supply clients with certain medicines either by prescribing from the Nurse Prescribers' Formulary or issuing under Patient Group Directions. For some clients, ameliorating the adverse effects of medication would have involved changes to prescribed antipsychotic medication; here decisions were more equivocal.

IMPLICATIONS

The identification of previously unattended problems, together with the views of service users, suggests that empowering nurses to address the 'care gaps' in medication management may benefit service users. The 'checklist evaluation' approach warrants further investigation, ideally in conjunction with nurse prescribing initiatives.

Assessing the skills for family planning nurse prescribing: development of a psychometrically sound training needs analysis instrument

RATIONALE AND AIMS

Family planning nurses have been identified for early development for prescribing authority in the United Kingdom (UK). Currently, no psychometrically founded training needs analysis instrument exists that can reliably assess the nature and extent of the specific educational provision required for this role. This paper is concerned with the development of an instrument capable of defining the development needs for family planning nurse prescribing.

METHODS

A national survey was conducted with 388 family planning nurses, using a modified training needs analysis instrument. Respondents were required to assess the importance of 40 tasks, firstly for the role of the family planning nurse (FPN), and again for the role of the family planning nurse prescriber (FPNP). The data from each set of ratings were separately factor analysed using orthogonal Varimax rotations and Cronbach's alpha was computed for each factor.

RESULTS

Six factors emerged from the family planning nurse ratings ('professional development', 'managing patient consultations', 'critical appraisal', 'clinical information giving and professional accountability', 'collaborative working and current National Health Service (NHS) issues' and 'dispensing of drugs') and nine factors emerged from the FPNP ratings ('research and practice development', 'prescribing and professional accountability', 'management/leadership', 'clinical decision making and risk assessment', 'advanced health assessment', 'critical appraisal', 'referral processes', 'core nursing skills' and 'dispensing of drugs'. This suggests that the role of the FPNP is more extended and, moreover, that the two roles are configured very differently but in a way that makes logical and coherent sense within existing research and government policy. This indicates that the instrument is valid. Moreover, all but two of the factors had a Cronbach's alpha score of >0.7 and so can be considered reliable.

CONCLUSIONS

The results indicate that the modified instrument is valid and reliable and therefore can be used with confidence to assess the training needs of FPNPs. In addition, the factors have outlined a cogent definition of the role of the FPNP, which can be used both to inform educational programmes and to assess their efficacy.

Research information in nurses' clinical decision-making: what is useful?

AIM

To examine those sources of information which nurses find useful for reducing the uncertainty associated with their clinical decisions.

BACKGROUND

Nursing research has concentrated almost exclusively on the concept of research implementation. Few, if any, papers examine the use of research knowledge in the context of clinical decision-making. There is a need to establish how useful nurses perceive information sources are, for reducing the uncertainties they face when making clinical decisions.

DESIGN

Cross-case analysis involving qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England, United Kingdom. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 hours and 122 nurses were involved in the Q modelling exercise.

RESULTS

Text-based and electronic sources of research-based information yielded only small amounts of utility for practising clinicians. Despite isolating four significantly different perspectives on what sources were useful for clinical decision-making, it was human sources of information for practice that were overwhelmingly perceived as the most useful in reducing the clinical uncertainties of nurse decision-makers.

CONCLUSIONS

It is not research knowledge per se that carries little weight in the clinical decisions of nurses, but rather the medium through which it is delivered. Specifically, text-based and electronic resources are not viewed as useful by nurses engaged in making decisions in real time, in real practice, but those individuals who represent a trusted and clinically credible source are. More research needs to be carried out on the qualities of people regarded as clinically important information agents (specifically, those in clinical nurse specialist and associated roles) whose messages for practice appear so useful for clinicians.

Mental health nurses' perceptions of nurse prescribing

AIMS

This study aimed to ascertain mental health nurses' perceptions of the advantages and disadvantages of nurse prescribing and to identify the educational needs of mental health nurse prescribers.

DESIGN

A questionnaire was designed and administered to a convenience sample in the UK of 73 mental health nurses in clinical practice, 14 working in in-patient settings and 59 in the community. Questions included both closed and open-ended items. Descriptive statistics were used for numerical data, and category analysis of the open-ended questions was undertaken by two of the researchers independently and then conjointly.

FINDINGS

The majority of respondents felt that mental health nurse prescribing would significantly improve clients' access to medication, improve compliance, prevent relapse and prove cost effective. However, many were anxious that they did not have sufficient knowledge and skills to assume responsibility for prescribing.

CONCLUSIONS

Although there would be benefits to clients and patients, further training, rigorous supervision and the co-operation of doctors will be required if mental health nurse prescribing is to yield the anticipated benefits.