Chapter 2. The role of nurses in drug administration
The nurse’s responsibilities
Drug therapy plays a major part in the treatment of patients. Traditionally, medicines have been prescribed by doctors and the nurse’s responsibilityhas been to ensure safe and reliable administration and to monitor side-effects. However, in 1994 the law was changed to allow district nurses and health visitors employed in pilot sites throughout England to prescribe from a limited formulary. Many of the preparations they were initially able to prescribe were for over-the-counter preparations. In 1998 it became possible for all appropriately qualified community nurses to prescribe from a limited nursing formulary. From 2003, any registered nurse could undertake training to enable them to become a nurse prescriber and prescribe from a broader Nurse Prescribers’ Extended Formulary. In 2006 the law changed again, enabling nurses who had undergone the requisite training to prescribe from the full range of drugs in the British National Formulary (with the exception of most controlled drugs) provided this was in their sphere of competence. The controlled drugs which nurses are able to prescribe are shown in Table 2.1.
• Diamorphine, morphine, diazepam, lorazepam, midazolam or oxycodone for use in palliative care • Buprenorphine or fentanyl for transdermal use in palliative care • Diamorphine or morphine for pain relief in suspected myocardial infarction or to relieve acute or severe pain after trauma, including postoperative pain • Chlordiazepoxide hydrochloride or diazepam to treat initial or acute withdrawal symptoms from people habituated to alcohol • Codeine phosphate or dihydrocodeine tartrate or co-phenotrope |
There are two models of nurse prescriber, collaborative (those prescribing in partnership with physicians to an agreed patient-specific, clinical management plan) and independent nurse prescribers. Independent nurse prescribers are now able to prescribe in agreement with their employers and clinical teams. To ensure that nurses are prescribing safely, their employers must:
• establish a risk management plan to ensure that potential risks are recognized and minimized
• ensure that the parameters of an individual’s prescribing are agreed by the prescriber, their manager or local professional lead and employer.
In legal terms, ‘prescribing’ is taken to mean the ability to make a personal, professional and independent assessment of the patient. Based on this, a free choice is made from the British National Formulary of the most appropriate drug or treatment. A doctor’s opinion is unnecessary. The nurse signs the prescription form and remains professionally and legally accountable for his or her actions. In primary care, each individual NHS prescription issued and dispensed is identified and monitored by the Prescription Pricing Agency (PPA).
Research studies have indicated that despite initial lack of confidence, nurses have responded well to the challenge of prescribing, and numerous benefits have been reported, including an improvement in patient care, more efficient use of nurses’ time, and clarification of professional responsibilities, which have resulted in better communication between members of the primary health care team.
Patient safety is the key issue and the thrust of the reforms is to benefit patients by permitting more rapid access to medicines. The service benefits because professional time is freed for those with more complex needs. The extension of the nursing role which has resulted from nurse prescribing is in line with health care policy in the UK and extending professional roles. Nurse prescribing policy applies only to qualified nurses and midwives and they must first complete a recognized non-medical prescribing (extended and supplementary prescribing) training course with assessments including competency-based practice portfolios signed by a medical supervisor.
Breakdown of communication is possible after the patient is discharged from hospital and when drugs may be prescribed by more than one person. The new prescribing–dispensing process means greater contact between the nurse and pharmacist, especially when problems arise. It has been recommended that prescribing records are stored in the patient’s home along with district nursing records. The prescribing record contains details of previous and current drugs, including any additional over-the-counter products and drug allergies. When prescribing, the nurse will need to consider psychosocial as well as physical factors and the need for patient education must be recognized. The record should monitor the response to drugs and reasons for discontinuing their use.
Irrespective of whether or not they are permitted to prescribe and the setting in which they are employed, however, all nurses need to help patients understand the purpose of their treatment and to promote adherence with taking medication. The nurse must be aware that his or her responsibilities in giving drugs are governed by the Misuse of Drugs Act 1971 and the Misuse of Drugs (Amendment) Regulations 2005, for controlled drugs, and the Medicines Act 1968, for prescription-only medicines, together with additional regulations formulated locally. All trusts have their own procedures and policies. The Nursing and Midwifery Council (NMC) code of conduct, in laying down the general responsibilities of the nurse, stipulates that his or her actions should put the patient’s safety and well-being first at all times.
In hospital, the custody and administration of drugs is the responsibility of the ward sister/charge nurse, who may delegate this responsibility as instructed by the employing authority’s policy. Although it is usual for a qualified nurse to give drugs, with a second nurse checking to prevent error, the NMC takes the view that registered nurses should be seen as competent to administer drugs on their own and be responsible for their actions. Student nurses will take part in drug administration and senior student nurses who have shown competence may be allowed to act as the senior person giving drugs. Nurses’ actions in relation to drug administration will be legally covered by the employing authority when the rules are followed.
Drug history
A reliable drug history should be obtained from the patient and, if necessary, from relatives or friends. This should include previous exposure to drugs, drugs being taken at the time and, in particular, any adverse effects resulting from their use. If the illness is of a recurrent nature, the efficacy of any drugs used in previous episodes should be noted.
It is important to remember that drugs include local applications, any over-the-counter or herbal remedies that may have been used, and recreational drugs.
The prescription
In hospital it is normal practice for all drugs to be prescribed. This enables the pharmacist to supply them and provide advice concerning administration. The prescription sheet, which is a primary document in the case records, must be headed with the patient’s full name, age, hospital number and ward. The prescription must be clearly and indelibly written and must contain the date, the approved name of the drug (preferably in block letters), the dose (using metric dosage), the route and frequency of administration with the validity period and signature of the medical practitioner. If any of these details are omitted, the drug should not be given until the prescription has been amended. Frequency of dosage can be ordered by filling in allocated time spaces rather than using Latin abbreviations. Administration is recorded by initialling the relevant box on the prescription sheet. The exact format of this sheet will vary between trusts, and nurses must familiarize themselves with documents in use when moving to a new trust.
Controlled drugs
In hospital, controlled drugs must always be given by two people and it is common practice for one to be a qualified nurse. Both nurses must sign the book following each administration at the bedside or in the presence of the patient. The prescription requires the number of doses in words and figures. An additional record is kept in a specially designed book so that every tablet or ampoule is accounted for when used, both nurses signing the book following each administration. The controlled drug record book is retained on the ward for 2 years after the date of the last entry. These are legal requirements for controlled drugs, but some trusts apply similar rules to other drugs liable to misuse.
Drug protocols
‘Protocols’, often known as clinical guidelines or standards, have long been used in hospital and community settings to provide written documentation for an agreed method of performing a particular procedure, to achieve continuity and to standardize care. Today it is common practice for drugs to be administered according to protocols in hospital and the community; for example, nurses may administer immunizations or oral contraception under protocol. The use of a protocol is distinct from nurse prescribing as the nurse is unable to make an independent choice of medication or treatment – this will already have been specified within the protocol. The protocol is operating as a substitute prescription authorized and signed by a doctor who remains legally and professionally accountable for the treatment of the patient. Nevertheless, the nurse remains professionally and legally accountable for his or her decisions within the use of the protocol.
Nursing aspects of administration
The nurse is responsible for interpreting the prescription accurately, recording that the drug has been given and observing the patient’s response. Prior to administration the nurse must know the reason for, action and usual dosage of the drug; this should enable him or her to recognize and question mistakes in prescribing. When in doubt about a prescription, advice should be sought and, if necessary, the doctor should be consulted. Observations should be made for therapeutic and adverse effects. The nurse should realize that the patient’s condition may alter the effect of a drug and that there may be interactions with concurrent treatment. The nurse is greatly assisted in these circumstances by the pharmacist, with whom a good working relationship will enhance the safety of patient care.
In the community, most patients, or some member of the family, are responsible for drug administration, although the nurse may have a role to play. Many people are now discharged within a few days or hours of surgery and the average length of stay for medical patients has also been reduced. People returning home are often still taking drugs which until recently would have been given only within the confines of a hospital, so monitoring for adverse effects is an increasingly important aspect of the community nurse’s role. The nurse must also be aware that some drugs, even if stopped before discharge, may still exert an action or cause side-effects.
The Committee on Safety of Medicines requests that adverse reactions are reported (yellow cards) and, in addition, may require that a special watch is kept on certain preparations (see p. 428).
Ward administration of drugs
Drugs may be given to the whole ward by the same nurses or to a smaller group of patients by those directly involved in their care. The second method is preferable as timing is more accurate and the nurse will know the patients well and can cater for individual needs such as difficulty in swallowing medication. Time can be spent teaching patients about their drugs and student nurses can take part to gain experience in relating drugs to the patient’s condition. In some hospitals, experimental schemes have involved patients being responsible for their own drugs, particularly if they need to take the same drugs when they go home. On the whole, these have been successful and have provided valuable opportunities for patient education. Where members of the family will be giving drugs, they can be invited to the ward at the appropriate time to practise a technique (such as giving an injection) or to ask about any anticipated problems. An innovative approach on some wards has been in the timing of drug rounds so that medicines can be given nearer the time patients would take them at home. Many people have taken their drugs at home for years and may be upset by altered timing in hospital. Many schemes have abolished the early morning drug round to give patients longer to sleep.
For a few drugs, flexibility is not possible; antibiotics are more effective if doses are spread evenly throughout the day, and insulin must be given before meals. Other drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) are best given with or after food.
Specific rules of drug administration
Whichever approach is taken, specific rules of drug administration must be followed to obviate errors. The underlying principles – to give the correct dose of the prescribed drug to the right patient, by the right route, at the right time – require the nurse’s undivided attention. When two nurses are involved, instructions should be read aloud:
1. Read the patient’s full name from the prescription sheet.
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