Nurse prescribing and patient group directives

Within your medical placements you may be exposed to a range of nurses who have completed an advanced course in nurse prescribing. Only those who have undergone appropriate training and are registered with the NMC as an independent prescriber can prescribe (NMC 2006). It must also be judged that it is part of the nurse’s role. Some clinical nurse specialists, advanced nurse practitioners, practice nurses, district nurses, health visitors and community matrons will have completed this course and will have undergone intensive supervision and academic assessment to meet the competencies required (Kaufman 2010).

Activity

Ask your mentor if there are any practitioners within your area who are nurse prescribers and find out if you can spend some time with them to discuss their role and how it fits in with day-to-day medicine administration by nurses in placement.

Self-administration

In some of your medical placements, patients may be self-administering their medication and there should be a policy within the organisation that supports this practice. Nurses must assess that the patient is willing to do this, has the knowledge and is not forgetful or confused before self-administering their medication. It can work very effectively for patients as they do not need to wait for a nurse to administer their medication and they are able to have control over this aspect of their care. Within the essential skills clusters, there is an expectation that student nurses will ‘involve people and carers in administration and self-administration of medicines’ (NMC 2010) and from your second year this will be one of your learning outcomes under the supervision and guidance of your mentor.

There is also an assessment that can be undertaken when admitting or discharging a patient. Nurses can make arrangements for medication to be packaged in different ways to aid compliance. This can be arranged on discharge to allow health and social care practitioners within the community to help patients take their medicines. The NMC expects nurses to continually assess their patients regarding the appropriateness of the medication compliance aid. Patients who have been taking long-term medication are usually very knowledgeable about their medication. The following are examples of compliance aids:

• Blister packs: the medication is packaged with the days of the week highlighted.

• Dosette boxes: the medication will be placed in a box with separate compartments for days and times by a nurse to ensure that the patient does not get muddled about which medication to take and when. This is very helpful when a patient has multiple medications to take every day (Fig. 10.1).

Fig 10.1 Dosette box

(Brooker C, Waugh A (2007) with permission)

Activity

When a patient is being discharged from your placement (if in hospital), what arrangements can be made for a patient who needs help to administer their own medications? Who would you need to refer the patient to and what information would they require? What policies would support this?

Covert administration of medicines means administering medicines to your patient without their knowledge, for example disguising it in food or drink. This is not considered good practice (NMC 2008a). If your patient is refusing their medicines, it is important that you first establish why they do not want to take them. Often it will be because they don’t know what they are or why they need to take them. Spending some time explaining the medicines and reassuring your patient may be all that is needed for your patient to agree to take their prescribed medicines.

An interesting article for you to read:

Griffith R, Griffiths H, Jordan S (2003). Administration of medicines part 1: the law and nursing. Nursing Standard 18(2):47–51. Online. Available at: http://nursingstandard.rcnpublishing.co.uk/archive/article-administration-of-medicines-part-1-the-law-and-nursing (accessed July 2011).

If you are not sure about the medicines, use this as an opportunity to brush up on your own knowledge. Your patient may be having difficulty swallowing their tablets and it may be possible to order them in a different preparation, for example as a liquid. Crushing medication could also affect its metabolism/absorbance and may alter the affect of the drug. This could cause harm to the patient.

It may be that your patient does not understand the importance of the medicines and the potential side effects of not taking them. In this case, the team looking after the patient will need to determine if the patient has capacity to decide whether to take the medicines (see Ch. 6 for a discussion on capacity). Within the Essential Skills Clusters (NMC 2010) there is an expectation that ‘people can trust the newly registered graduate nurse to work within the legal and ethical frameworks that underpin safe and effective medicines management’.

If it is decided that a patient does not have the capacity to make the decision, the multidisciplinary team, along with those who know the patient best (e.g. relatives/carers), must make a decision in the best interests of the patient and this may be to administer medicines covertly. If this is the case, how and when the medicines are given must be decided and documented clearly in the patient’s notes. This decision must also be regularly reviewed.

As you progress in your nurse training, your learning outcomes will incorporate ethical issues in relation to medicines and consent. You will need to be able to demonstrate that you are aware of religious, cultural and ethical beliefs pertaining to medications and that you are sensitive to these issues.

This Website provides information to patients regarding Ramadan and there is a comprehensive section relating to medicines:

http://www.nhs.uk/Livewell/healthyRamadan/Pages/Healthyramadanhome.aspx (accessed July 2011).

Activity

Have any patients been reluctant to take their medications within your placement areas? Discuss the actions that you have taken with your mentor.

The reasons patients give might include the following:

Can’t swallow tablets.

Too many tablets.

Feel sick or afraid of vomiting.

Don’t understand why they need them.

Diuretics make them incontinent.

Confusion.

Medicines management for controlled drugs

Since the fourth report of The Shipman Inquiry (2004) there has been tighter legislation in relation to controlled drugs, and nurses need to familiarise themselves with the latest NMC, Department of Health and local trust and university policies. As a student, you will be placed in a variety of placements – community, independent sector and acute sector trusts – and will need to make sure that you are aware of the placement policies regarding controlled drugs. The NMC (2008a) emphasises that student nurses must be involved in the administration of all medicines when they are deemed competent by a registrant and also feel confident and competent themselves. One of the essential skill outcomes states that ‘people can trust the newly registered graduate nurse to safely order, receive, store and dispose of medicines (including controlled drugs) in any setting’ (NMC 2010).

Controlled drugs are kept in a double-locked cupboard and the nurse in charge will hold a separate set of keys to this cupboard. These keys are not to be left on hooks in the office nor on the ward desk, but on the person of the key holder at all times.

The national guidance for drugs considered to be controlled drugs can be found here: