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Research: non-medical prescribing by HVs

08 March 2019

Dr. Alan Massey
a.massey@chester.ac.uk

Dr. Alan Massey
a.massey@chester.ac.uk


Introduction

When non-medical prescribing (NMP) was introduced in 1986, one of the stated aims was to develop pathways for primary intervention by community practitioners so that they could enhance their role, improve care and provide choice for clients (Brooks, 2013). To meet this aim, community practitioners such as District Nurses and Health Visitors (HVs) can prescribe independently from a formulary on completion of enhanced training such as the V100 programme. This formulary is representative of commonly used medicines, dressings and products suitable for use in community settings (Dowden, 2016). HVs are expected to utilise the NMP formulary for preventative reasons in line with their public health function (Dowden, 2016). Leavell and Clarke (1953) introduced a mechanism for preventative work via three distinctive approaches, which are still in use today. Primary or early interventions are those which seek to avoid health complications before they arise. Secondary interventions or maintenance interventions are used to prevent disease progression, and tertiary interventions are used for rehabilitation purposes. Primary intervention can be the key to positive change in young families (Department of Health 2012). However, to be effective in providing primary interventions, HVs must have the appropriate resources (Bishop et al, 2015).  Kroezen et al (2012) highlights that the present resources within the formulary for NMP are better suited to the work of community practitioners who focus on secondary or tertiary interventions rather than HVs who focus on primary interventions. Kroezen et al (2012) add that, by focusing on a broad approach to NMP, then opportunities for improved health outcomes are being missed. This study seeks to ascertain the views of a group of HVs in the North West of England toward this phenomenon.  

Study aims and objectives

This study aims to gain insight, understanding and find meaning in the phenomena of NMP prescribing by HVs within the provision of primary preventative care. 

The specific aims of the study are:

  • To gain an understanding of HVs’ experiences of NMP.
  • To explore HVs’ meanings of NMP within the context of upstream preventative work.
  • To gain insight into the ways HVs utilise knowledge, skills, competencies and confidence to deliver upstream preventative work within the context of the NMP formulary. 
  • To gain insight into HVs’ use of the resources they may need to facilitate upstream preventative work within the NMP formulary

Method

This research adopted a qualitative perspective. Qualitative research accepts the idea that each individual experiences the world differently and that these differences are best explored by analysis of language (Smith et al, 2009). It is the exploration of these differences which allows us to gain deeper insight into the underlying reasons, opinions and motivations of peoples’ actions (Bryman, 2016). Phenomenolgy researches peoples’ experiences of the world, and can be used to either describe or interpret the world as experienced individually (Smith et al, 2009). This research chose to describe HVs’ experiences of NMP.    

Descriptive Phenomenology Analysis (DPA) is a research method, which allows researchers to give voice to how people make sense of their experiences (Elliott and Timulak, 2005).  It allows the researcher to describe data and to explore which concepts lie behind experiences (Elliott and Timulak, 2005).  DPA is concerned with meaning and processes rather than events and causes. To ensure research is undertaken appropriately and meaning emerges appropriately then a systematic approach should be utilised. By following a systematic approach, the research can be considered trustworthy and representative of the views of those being researched (Cohen et al, 2000). Trustworthiness and meaning making are established by embracing the relationship between researcher and participant. This allows the researcher to engage in critical reflection via the reflexive activity of writing and re-writing (Cohen et al, 2000). This in turn leads to the identification of patterns or themes for analysis. These themes are then analysed in light of accepted knowledge with the intention of identifying if any new knowledge emerges. Therefore, the research approach taken will be transcription of first-person interviews using semi-structured questionnaires (Bryman, 2016).

Ethics

Ethical approval was obtained from the local ethics research committee and from the University of Chester’s research committee. The research was mindful of the application of all ethical principles and of the need to protect the researched from harm. 

Participants

Eight HVs who met the inclusion criteria were approached via purposive sampling and agreed to take part in the study. All eight provided informed consent.

Data Collection

Interviews were conducted in the HVs’ place of work. Informed consent and issues of confidentiality were re-explained. A semi-structured interview lasting 30 – 45 minutes took place, which was recorded and audiotaped. A relexive journal was kept by the interviewer. A reflexive journal is used in phenomenology so that the researcher can explore, via reflection of each stage of the research, the effect they have on the research process in an attempt to reduce researcher bias (Bryman, 2016). It is important to reduce bias so that the research reflects the HVs’ viewpoint rather than the researchers’ viewpoint.

Data analysis

The interviews were transcribed and analsyed using Colaizzi’s (1978) framework.  This framework was chosen as it allowed for clarity of interpretation. Colaizzi’s framework involves seven distinct stages. These move from description at the level of each individual case; identification of significant statements relevent to the research question; initial analysis of significant statements and development of a thematic frame; grouping of similar themes into categories and provision of a description of the topic. The final element of Colaizzi’s framework is to undertake member checking to ensure trustworthiness of the descriptive account (Colaizzi, 1978).  

Results

Study sample description

All the eight participants were female. Their age range was between 24 and 64 years old. There was a mixture of experience ranging from two years’ experience to 20 years’ prescribing experience. Two HV were also qualified midwives, one HV had a background in child nursing, while the rest were adult nurses prior to becoming HVs. In presenting the research findings, pseudonyms will be used. Six HVs held the SCPHN qualification. From the eight participants studied, fifty-five significant statements were extrapolated, and eight common themes emerged. The themes will now be outlined.

Time constraints 

“I believe we are uniquely placed to make a change (with families) but we don’t always have time afforded to it (prescribing).” Alison. 

This theme was stated by all those interviewed and outlined the dominant concern HVs had with their role as preventative practitioners. 

Limitations of the formulary

The limitation of the formulary was discussed by all respondents in terms of the time taken to prescribe and the amount of bureaucracy involved. Additionally, the focus of NMP updates are described as an irrelevance to the HV role. This is because the updates address the needs of other community practitioners rather than their own.   

Continuous professional development

The lack of focused continued professional development (CPD) reduced perceptions of confidence and professional ability in the eyes of the HVs.

“I always tend to prescribe the same products as I’m not too familiar with some of the others…I wouldn’t feel confident in prescribing for a baby’s bowels as we have no support or training that covers it.” Caroline. 

Participants disclosed that HV updates were poor to non-existent, and concluded that the HVs studied never stray far from what they know, despite being aware that this was a limitation. None felt comfortable prescribing for complex issues as they lacked confidence due to a lack of resources available to them.

Similarly, routine clinical updating was an irrelevance; 

“V100 meetings are geared towards district nurses so I don’t go, I’m too busy – we should have separate HV ones.” Chelsea

All the HVs outlined that the V100 meetings were inappropriate for them, being more focused on the district nurse, with HVs desiring their own clinical prescribing updates. 

Knowledge and competence

The focus of the formulary created role frustration for many of the respondents as they felt they could not practice to their full potential; 

“We know more about reflux and milk intolerance than the GPs. However, we send clients to them for treatments.” Alison.
Participants highlighted how they felt that the formulary could be expanded to allow for greater alignment with the HV role, and an improved service in terms of quality and resources utilised for clients. 

Resources

Lack of resources issued by the Trust to facilitate NMP was highlighted by participants as being a barrier to prescribing;

“We’ve been without a BNF [British National Formulary] for a long time and before that we had no up to date NPF [Nurse Prescribers' Formulary]. I don’t know how the commissioners can let that happen as it’s integral to our prescribing abilities…not having the equipment to deal with it.” Isabel.

It is evident that practitioners perceive that the Trust’s failure to supply the relevant resources needed in order to carry out NMP was a source of concern.

Relationships

Inter-professional relationships were problematic within NMP as it was felt that the NMP role hindered their relationships. Relationships with general practitioners (GPs) was a concern;

“The fact that I can’t prescribe (no pad) doesn’t improve our relationship with the GPs, I have to send my clients directly to the GP for minor things… I’m embarrassed as I’m unable to carry out my job effectively.” Julie. 

Similarly, the issue of inconsistent HV practice within a geographical area raised concerns. In particular, the experience and skill mix of HVs from different practices working for the same GPs influenced working relationships. It was felt that newly qualified HVs who could not prescribe due to a lack of experience or training caused frustration amongst GPs. Specifically, the process of prescribing by GPs was increasing the GP workload and led to a perceived erosion of the preventative HV role.  

Other participants argued that they were better placed than the GPs to prescribe as they believed their front-line status meant they were more accessible. This was further supported through the HVs confiding that their knowledge of minor skin conditions in babies and children was more up to date than the GPs’, therefore it was felt safer that a HV prescribe.  
Public health
The subject of models of health arose with regards to the perceived shift away the public health model and into the medical model; 

“Prescribing brings us very much into the medical model when we have been moving towards the public health model for quite some time now. Public Health models don’t include prescribing.” Rebecca

Clinical Commissioning Groups 

The final issue raised within this research concerns the borders between Clinical Commissioning Groups [CCGs] considering the National Health Service restructuring;  

“Boundary and border issues with GPs within our geographical caseloads have been very poorly thought out. This directly effects prescribing decisions…huge barriers…we don’t have GP codes for over the border so immediately those families will not be issued a prescription from me, even if I thought it necessary.” Barbara

The evidence has highlighted that HVs do recognise a role for themselves with NMP. However, they feel several pressures, which are out of their control, mitigate their effectiveness. All the HVs interviewed felt they were well-placed for prescribing intervention, however they appeared to feel disempowered in many circumstances.

Discussion

The dominant issue highlighted within this research is the notion of time and whether time within NMP is well spent. Additionally, issues of CPD are frequently cited as a principal matter of concern for HV within NMP practise (Smith et al, 2014). Within this study, the issue of appropriate CPD was also highlighted as being significant. This study expands on previous research by highlighting the effects of a lack of engagement with CPD on the perceived role of HVs and the effect of perceptions of role ambiguity on interdisciplinary working. Additionally, this research highlights the concerns of HV on recent health reforms. Working relationship with GPs is seen as suboptimal within the NMP agenda.

There was unanimous agreement within this research that CPD opportunities are insufficient for the development of HV/NMP practice. The lack of credibility as perceived by HVs in current CPD practice is evident in the lack of engagement with clinical updates. This finding is at odds with the work of Young (2009) who found that HVs were generally happy with CPD. Our research indicates that there is a growing frustration among HVs in this area of practice. Participants admitted to not attending the V100 updates as they perceived them to be a waste of time. Respondents stated that CPD sessions were not suited to the HV role as they focused on predominantly medicalised treatments or treatments better suited to other community practitioners. This result mirrors the work of Kroezen et al, (2012) and Bishop and Gilroy (2015). The implication here is that HVs are resisting current trends towards the medicalisation of their role. 

All the respondents evidenced contradictory perceptions towards the process of NMP. Respondents indicated that they were confident in prescribing certain routine products. However, there appeared to be a discrepancy on deciding whether NMP was part of the HV core role. It appears from this research that the formulary is outdated and requires review from a HV perspective if NMP is going to be perceived as an efficient use of time. This finding echoes the work of Kroezen et al (2012). Participants were enthusiastic about the possibilities offered by NMP. However, this research identified that the formulary was not fit for purpose from a HV perspective (Brooks, 2013). HVs highlighted that the inclusion of specialist infant milks and a reflux treatment would enable them to be able to prescribe more readily for clients, as those products were more relevant for them and they had more understanding of them than the GPs who currently prescribed them. Courtenay and Griffiths (2004) identified similar findings in their research, and it appears that restrictions on prescribing practice are a constant source of tension for HVs. 

The participants recognised the importance of good inter-professional working relationships with GPs. However, the respondents felt frustrated by the impact that prescribing had on inter-professional working. The overall sentiment was that prescribing does not improve working relationships for several reasons. Predominant was the perception that GPs found the different levels of knowledge, nursing experience and competence a source of frustration. This is a new finding and requires further exploration. The respondents felt that the lack of unified practice across a geographical area and between HV services eroded confidence in all HVs. McInnes (2015) advocates for the use of preceptorship in health visiting due to the need for a seamless transition from student to experienced practitioner to address these concerns. This research supports this view. Similarly, the requirement of the NMC for a period of consolidation before being permitted to undertake NMP was perceived as a source of frustration. The lack of uniformity of HV practice is an area for further research as it appears that NMP practice is not meeting the expectations of these working groups (Bishop & Gilroy, 2015). Our research supports the view of Watterson (2017) that inter-professional working is central to effective preventative care and that numerous barriers to inter-professional working still exist. This is despite an excess of policy initiatives aimed at improving inter-professional education so that role understanding occurs, and that integration of services arises to meet the HV implementation plan (Watterson, 2017).  

This theme of integrated care re-emerges within debates around models of practice, and the tensions between the public health model favoured by HVs, and the medical model favoured by GPs. The focus of prescribing within the medical model was a barrier to the development of effective public health practice for HVs (Brooks, 2013). There is incongruence between the predominantly public health approach favoured by HVs, and the reality of the dominance of the medical model, which is embedded in the NMP formulary; the outcome of which is role ambiguity for the HVs. Similarly, the suitability of the formulary to district nursing practice was a threat to HV role development. Research by Davy et al (2015) indicates that preventative models of care are being subsumed by the need to address chronic illness, and that addressing those with disease, such as the ageing population, takes priority over the needs of those without disease, such as young families. This research would support this view. Health reforms and the reduction of available resources is viewed as problematic for HV practice. Whilst government reforms have debated the development of the public health role, scarce resources and a shift of focus toward chronic disease management have reduced opportunities for engagement with preventative work (Davy et al, 2015). The general feeling appeared to be that HVs have the skills and opportunities to facilitate NMP within the public health model. However, they argued that they were faced with reducing opportunities for client contact, such as the lack of clinic time. This appears to have put prescribing further down their list of priorities. This element supports the work of Davy et al. 

Current health reforms were a barrier to the development of the HV role. There was evident frustration that a lack of resources was threatening safe and effective NMP practice. Participants were keen to discuss the lack of NMP and British National Formulary books available to them, which were not the latest editions. Along with the complications of re-ordering prescription pads. The politically changing geographical boundaries of the area chosen for this study, and how GP practice borders sometimes did not correlate with the HV geographical footprint, was also seen as a drain on resources and time. This element emerged within our research and is worthy of further investigation.  

Time was the most common theme to run through the thread of the interviews as all participants believed it to be a specific barrier to prescribing. The prescribing activity was believed to generate more paperwork, create a larger paper trail, incur gratuitous visits and generally create a time pressure that impacted on the rest of their duties. It appears that time has a huge impact on the decision of whether an NMP will choose to prescribe or not. This finding is in line with other researched work. 

Conclusion

In conclusion, this sample of HVs judged that overall NMP was problematic. Firstly, from a resource perspective, not enough time and physical resources are available to allow HVs to function effectively in this role. Training mechanisms, such as CPD, are a waste of time and effort due to a medical focus. From a professional perspective, the formulary was seen as limiting the HV role and in some cases created tensions with other professional colleagues. Finally, NMP was not seen as an effective mechanism in the drive to create client choice.  

Recommendations 

A review of the NMP formulary from a HV perspective is undertaken.
A period of preceptorship becomes standard practice for newly qualified staff.
Inter-professional education is enhanced for HVs.
HV specific NMP and CPD updates are developed.
Further research is undertaken into the effect of CCGs on the role of HVs. 

Declaration

Funding: The authors confirm that no funding was received to support this study.

Ethical approval: University of Chester Research Ethics Committee.

Conflict of interest: none.


 

References

Bishop P, Gilroy V. (2015) Non-medical prescribing by health visitors in 2015. Nurse Prescribing, 13(8), 390-397. See https://www.magonlinelibrary.com/doi/abs/10.12968/npre.2015.13.8.390 (accessed 20 February 2019).

Bishop P, Gilroy V, Stirling L. (2015) A National Framework for Continuing Professional Development for Health Visitors: Standards to support professional practice. Institute of Health Visiting, London. See https://ihv.org.uk/for-health-visitors/resources/frameworks/ (accessed 20 February 2019).

Brooks C. (2013) Developing health visitor prescribing. Community Practitioner, 86(4). 28-30. See https://www.ncbi.nlm.nih.gov/pubmed/23646816 (accessed 20 February 2019).

Bryman, A. (2016) Social research methods. Oxford university press.

Cohen M Z, Kahn DL, Steeves RH. (2000). Hermeneutic phenomenological research: A practical guide for nurse researchers. Sage Publications.

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Davy C, Bleasel J, Liu H, Tchan M, Ponniah S, Brown A. (2015) Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review. BMC health services research, 15(1), 194. See https://www.ncbi.nlm.nih.gov/pubmed/25958128 (accessed 20 February 2019).

Courtenay M, Griffiths M. (2004). Supplementary and independent prescribing: an essential guide. Cambridge: Greenwich Medical Media Ltd.

Department of Health. (2012) Caring for Our Future. London: The Stationary Office. See https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/136422/White-Paper-Caring-for-our-future-reforming-care-and-support-PDF-1580K.pdf (accessed 20 February 2019).

Dowden, A. (2016) The expanding role of nurse prescribers. Prescriber, 27(6), 24-27. See https://onlinelibrary.wiley.com/doi/abs/10.1002/psb.1469 (accessed 20 February 2019).

Elliott R, Timulak L. (2005) Descriptive and interpretive approaches to qualitative research. A handbook of research methods for clinical and health psychology, 1(7), 147-159.

Kroezen M, Francke A, Groenewegan P, Van Diik L. (2012) Nurse Prescribing of medicines in Western European and Anglo-Saxon countries: A survey on forces, conditions and jurisdiction control. International Journal of Nursing Studies 49.1002-1012. See https://www.ncbi.nlm.nih.gov/pubmed/22369921 (accessed 20 February 2019).

Leavell HR, Clark EG. (1953) Textbook of Preventive Medicine. McGraw Hill publishing.

McInnes, E. (2015) A Preceptorship Model for Health Visiting. Community Practitioner, 88(10). See https://www.ncbi.nlm.nih.gov/pubmed/26596134 (accessed 20 February 2019).

Smith A, Latter S, Blenkinsopp A. (2014) Safety and quality of nurse independent prescribing: a national study of experiences of education, continuing professional development clinical governance. Journal of advanced nursing, 70(11), 2506-2517. See https://www.ncbi.nlm.nih.gov/pubmed/24698501 (accessed 20 February 2019).

Smith JA, Flowers P, Larkin M. (2009) Interpretative phenomenological analysis: theory, method and research. Sage Publications Ltd, London (2009).

Watterson A (Ed). (2017) Public health in practice. Macmillan International Higher Education.

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