28 | Community Practitioner April 2013 Volume 86 Number 4
PROFESSIONAL AND RESEARCH: PEER REVIEWED
Christina Brooks RN (Adult) RM SCPHN (HV) BSc(Hons) Community Practitioner Nurse Prescriber Clinical Team Leader for Health Visiting and School Nursing Leicestershire Partnership Trust
Correspondence: Christina.Brooks@leicspart.nhs.uk
Key words Non-medical prescribing, health visitors, clinical updates, support, V100, Call to Action
Abstract Prescribing is an essential element of the health visitor’s role. However, in one inner-city locality prescribing in practice was evaluated to be at a low level. A number of barriers to prescribing were identified through a focus group. A project to support health visitors was planned and delivered. The project involved clinical updates and improvement to the registration process, thereby reducing delays for practitioners in getting prescribing pads. The result was that prescribing confidence improved and prescribing activity increased.
Community Practitioner, 2013; 86(4): 28–30.
Conflict of interest: none
Developing health visitor prescribing Background Non-medical prescribing (NMP), specifically
the V100 qualification, has been an inherent
part of health visitor and district nurse
training since 1999 (While and Biggs, 2004). It
is also an important element of the specialist
community public health nursing (SCPHN)
course for health visitors and school nurses.
However, evidence, both anecdotal and
through a data activity report taken from the
online prescription services database ePact,
demonstrated that prescribing activity in
the health visiting service was at a low level.
Therefore, a project to develop non-medical
prescribing in the health visiting and school
nursing services in an inner city locality
was planned.
Background and context NMP was first proposed in the Crown Report
(Department of Health (DH), 1989). The
benefits to clients identified in the report
included better use of time for clients and
nurses, and improved patient care.
NMP has evolved to allow allied health
professionals and nurses to prescribe from
the whole British National Formulary (BNF)
within their specialty. This has been evaluated
as beneficial for clients, nurses and their
organisations (Courtenay, 2010). This form
of prescribing is known as independent
prescribing and the qualification is called
V300; however, this project focused on
community practitioner nurse prescribers
who have the V100 qualification; specifically,
health visitors. This qualification allows
health visitors, school nurses and district
nurses to prescribe for their clients from the
Nurse Prescribers’ Formulary for Community
Practitioners (NPF).
There are now more than 50,000 nurse
prescribers registered with the Nursing and
Midwifery Council (NMC) (Culley, 2010).
However, although health visitors were
among the first professionals to adopt the
role, enthusiasm remains low and prescribing
practice is patchy (Young et al, 2009; Hall et
al, 2006; While and Biggs, 2004). Hall et al
(2006) found that only 50% of health visitors
with a V100 qualification prescribe for their
clients.
Research has been conducted with health
visitor prescribers (Young et al, 2009; Davies,
2005) and the themes that emerged focused
on good-quality patient care and time saved
for clients. A negative factor was extra time
pressure placed on the practitioner. Young
(2009) recommends that regular updates and
educational sessions should be implemented.
A number of authors have highlighted
the importance of continued professional
development (CPD) and support for
non-medical prescribers (Otway, 2002;
Ford and Otway, 2008; Hall et al, 2006;
Courtenay, 2010). The NMC (2006) states
that maintaining one’s own competence
through CPD is a requirement to
maintain prescribing registration and
Resisters
Extra time for the professional
No continued professional development sessions offered
Out-of-date formularies
Health visitors are not based with GPs; how to inform GPs about prescriptions
Need clear guidelines on how to follow clients up
Don’t know how to get hold of prescribing pads in timely manner
Table 1. Force-field analysis
Drivers
Professional autonomy
Prescribers want to keep up the skill and feel confident
The best treatment and care for the client
Policy driven
Cost-effective treatment
Better technology with use of SystmOne
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PROFESSIONAL AND RESEARCH: PEER REVIEWED
the non-medical prescribing policy in
the Leicestershire locality also has this as
a requirement.
The project The author had recently taken on the role of
non-medical prescribing lead for children
in an inner city locality, mainly supporting
health visitors. Through anecdotal and
personal experience it was identified that
there had been limited clinical updates
arranged for the V100 prescribers for a
number of years. To maintain competence
and confidence in prescribing, regular
updates and support sessions should be
available for staff.
A report of prescribing activity was
undertaken using the ePact system and it was
identified that health visitor prescribing was
at a very low level in the local area. Twenty-
five health visitors, of the 63 who have the
qualification, had written a prescription over
a one-year period. Of these, five health visitors
had written more than five prescriptions in a
year – so they were more regular prescribers.
The ePact report is evidence that Hall’s
(2006) research, which found prescribing
rates of less than 50%, is born out in the
locality in question. The issues this raised
were the potential for poor patient service,
as they were not receiving seamless care; cost
to the patient’s time; cost to the GP’s time
and budget for unnecessary appointments;
and unused clinical skills, leading to a lack
of confidence. These findings mirror those of
Hall et al (2006) and Thurtle (2007).
The project set out to engage with the
health visitor prescribers in an inner-
city locality. Clinical update sessions were
delivered and support offered. This extra
support aimed to improve health visitors’
confidence and address their values regarding
their prescribing skills. The support
offered encouraged more practitioners to
prescribe for their clients in the appropriate
circumstances.
The project met the Quality, Innovation,
Productivity and Prevention (QIPP) strategy
(DH, 2012). The development of the existing
service was in line with current English DH
policy drivers, including the Health Visitor
Implementation Plan: A Call to Action (DH,
2011) and Equity and Excellence: Liberating the
NHS (DH, 2010).
To engage with health visitor prescribers
a focus group was held and views were
expressed regarding barriers to prescribing.
These were: l Time – takes more time in clinic to write a
prescription l GPs – how to inform them l Not receiving prescribing pads in a
timely manner l Checking a child’s records before
prescribing l Not having up-to-date formularies (NPFs) l What to do about repeat prescriptions l What to do about following up prescribed
items l CPD sessions not offered l Prescribing off label – nystatin/miconazole
– what are the guidelines? l Workload l Samples of creams and emollients – what
are the guidelines?
Table 1 demonstrates the drivers and resisters
identified; the stronger drivers and resisters
are in bolder and larger text. Professional
confidence and best care for clients are the
drivers to focus on and to achieve this the
resisters must be tackled. To ensure a force-
field analysis is of use the resisters have to
be decreased (Iles and Sutherland, 2001);
therefore, those tackled were the lack of
clinical update sessions and the out-of-
date formularies. The drivers and resisters
were identified during the focus group
session through the emerging discussion.
The author’s usual role was a health visitor
practice teacher so clinical update sessions
Table 2. SWOT analysis: internal and external factors
Internal factors
Strengths l Local champions who have confident
and safe practice to share l The lead nurse in the new organisation
is chairing an organisation-wide NMP meeting
l Information has been shared with the lead for patient safety and quality
l Over 40 staff have attended clinical update sessions in the last 4 months and the sessions are evaluated very positively
l Staff are aware that I am the lead and to contact me with any queries
External factors
Opportunities l Call to Action: increased commitment to
health visiting gives us an opportunity to promote ourselves
l Better service for the clients, saving time l More holistic advice for clients. Research
shows that NMP is highly valued by patients and is very safe
l It is an efficiency saving during a time of NHS cost-saving exercises
l Increase the profile of the service among GPs and with new CCGs
l Could be developed as a Commissioning for Quality and Innovation (CQUIN) payment framework
l Specialism in specific areas, ie dermatology
l Improved technology with computerised records (SystmOne); easier for GP communication
l SystmOne and ePact can be used to monitor prescribing activity
Weaknesses l Different policies and procedures in
place due to recent organisational merger
l Historical issue of low priority given to NMP
l Very low number of health visitors prescribing
l Very slow system to get registered and get prescription pads
l No clinical update sessions offered for the last five years
Threats l Staff have to be proactive to inform the
manager when employed that they are prescribers and need support
l Staff can lose confidence and find barriers to prescribing
l Prescribing is compulsory for newly qualified health visitors
l Managing diplomatic relationships with the GP as prescriptions come off their budget
l Will extra prescribing put more pressure on the health visitor service?
l Will GPs bounce the client back to the health visitor service?
l Pharmaceutical companies and samples can influence choice of product
l Practice within team working can be insidious so there may be negative influences
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PROFESSIONAL AND RESEARCH: PEER REVIEWED
were planned and delivered by the author.
The sessions were attended by about 90% of
the health visitor and school nurse prescribers
and were evaluated very positively.
Comments included: ‘Session very useful, I
will order my pads this week’; ‘More sessions
like this should be offered’; ‘Has increased
my confidence and answered all my queries
about prescribing’; ‘SystmOne information
was very helpful’ (SystmOne is the electronic
record keeping system used in the area, part
of the clinical update focused on record
keeping).
Every practitioner was given an up-to-
date NPF. A flowchart on how to inform
the non-medical prescribing lead of a
prescribing qualification and how to obtain
prescription pads was devised. All managers
were informed of the process so they could
ensure new starters were promptly encouraged
to order their pads and use their prescribing
skills.
As the project developed, further
advancement and opportunities became
clearer therefore it was necessary to formulate
the current position, taking a view from
stakeholders. A group of six staff, including the
pharmacist lead, senior manager and health
visitor prescribers, met together and identified
the internal and external factors influencing
the project, thus formulating an analysis of
Strengths, Weaknesses, Opportunities and
Threats (SWOT) (see Table 2).
The SWOT analysis raised a number of
issues within the ‘Threats’ dimension and
it was not possible to address all the issues
until the prescribing activity increased. For
example, will extra prescribing put more
pressure on the health visiting service? This
was yet to be proven; however, the extra
prescribing was also an opportunity to
promote our service as cost-effective and so
develop a Commissioning for Quality and
Innovation (CQUIN). Another threat was
that practice within the health visitor teams
can be insidious; therefore, if the culture
within the team is not to prescribe then
it can be difficult to change that culture.
The SWOT analysis would be useful as an
ongoing working tool to revisit throughout
the project. Within a SWOT it is necessary to
keep focus on the weaknesses and threats and
turn them into strengths and opportunities.
A further report was taken from ePact
in August 2012 comparing the first three
months of 2011 to the first three months of
2012 to review if prescribing had increased
following training and intervention.
This demonstrated an increase of items
prescribed from 185 items to 261 items and
showed that 10 practitioners had started
to prescribe regularly, this was an increase
from the original five regular prescribers.
This demonstrates that the project had
achieved its aim; however there are on-going
challenges to keep up the momentum as part
of the increasing health visitor numbers due
to the Health Visitor Implementation Plan
(DH, 2011).
Evaluation This project identified that health visitor
prescribing was at a low level in the local
area for a number of reasons. The main
issues were that there had been no clinical
update sessions and that the health visitor
prescribers did not have up-to-date NPFs.
Record-keeping guidance on how to input
prescriptions onto SystmOne was also
needed.
User involvement identified the barriers
and clinical update sessions were planned
and delivered focusing on the barriers. New
NPFs were made available to each prescriber
and a clear process to request pads was put in
place. Support and guidance for staff helped to
enhance their confidence.
All of the above support demonstrated an
increased level of health visitor confidence
and an increased level of prescribing activity.
The number of health visitors is expected
to increase in the local trust in the coming
months, so processes are necessary to support
newly qualified health visitors to use their
prescribing qualification.
Positive feedback and enthusiasm from the
staff attending the updates was beneficial and
the project demonstrated some noticeable
changes in practice to benefit clients, staff
autonomy and the organisation.
The project continues to progress positively
and further areas of exploration include: l To offer update sessions to school
nurse prescribers
l To offer clinical updates as part of essential
role training on an annual basis. These may
be on specific clinical topics with a focus
on prescribing, such as dermatology l If staff have not attended training and do
not wish to be a prescriber, their NMC
prescribing qualification has to be discussed
at their Personal Development Review as
their competency as a prescriber is doubtful l Possible development of the project to meet
the CQUIN payment framework.
References Courtenay M. (2010) Nurse prescribing: a success story. Primary Health Care 20(8): 26.
Culley F. (2010) Professional considerations for nurse prescribers. Nurs Stand 24(43): 55–60.
Davies J. (2005) Health visitors’ perceptions of nurse prescribing: a qualitative field work study. Nurse Prescribing 3(4): 168–72.
Department of Health (DH). (1989) Report of the advisory group on nurse prescribing Crown 1. London: DH.
DH. (2010) Equity and Excellence: Liberating the NHS. London: DH.
DH. (2011) Health Visitor Implementation Plan 2011–15: A Call to Action. London: DH.
DH. (2012) QIPP. Available from: www.dh.gov.uk/ health/category/policy-areas/nhs/quality/qipp/
Ford K, Otway C. (2008) Health visitor prescribing: the need for CPD. Nurse Prescribing 6(9): 397–403.
Hall J, Cantrill J, Noyce P. (2006) Why don”t trained community nurse prescribers prescribe? J Clin Nurs 15: 403–12.
Iles V, Sutherland K. (2001).Organisational change: A review for health care managers , professionals and researchers. London: National Coordinating Centre for the Service Delivery and Organisation.
Nursing and Midwifery Council (NMC). (2006) Standards of proficiency for nurse and midwife prescribers. London: NMC.
Otway C. (2002) The development needs of nurse prescribers. Nurs Stand 16(18): 33–8.
Thurtle V. (2007) Challenges in health visitor prescribing in a London primary care trust. Community Pract 80(11): 26–30.
While A, Biggs K. (2004) Benefits and challenges of nurse prescribing. J Adv Nurs 45(6): 559–67.
Young D, Jenkins R, Mabbett M. (2009) Nurse prescribing: an interpretative phenomenological analysis. Primary Health Care 19(7): 32–6.
l Health visitors required continued professional development (CPD) sessions to maintain their confidence in prescribing
l A clear registration process ensured that health visitors got their prescription pads in a timely manners
l Health visitors increased their prescribing activity if support and CPD is robust l The ‘Call to Action’ requires a robust support system for newly qualified health visitors to
prescribe with confidence
Key points
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