Capstone: Impacting Factors

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

April 2013 Volume 86 Number 4 Community Practitioner | 29

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

30 | Community Practitioner April 2013 Volume 86 Number 4

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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Impacting Factors Tool Resource

Instructions: Use this tool to document your assessment of the factors impacting the capstone project. Be sure to cite and reference necessary sources according to APA format, using the last page for your reference list.

Name: ______________________________________________________________________

 

 

Stakeholder Identification and Engagement Strategies to Secure Support

( SWOT based on Problem Statement from WS One. Each SWOT will be unique. )

 

 

Stakeholder- anyone person or organization affected by or through the changed process.

· Patients

· Patients family members

· Organizational departments

· Co-workers

· Physicians

Engagement Strategies to secure support-

· Communicate plan clearly and consistently

· Acquire management buy in

· Background research to support proposal

 

SWOT Analysis-is used to complete an objective analysis of the capstone project.

 

Strengths and Weaknesses are internal organizational factors that may be controlled within the organization.

 

Opportunities and Threats are external factors to the organization that cannot be controlled by the organization.

 

Opportunities not acted upon can become threats.

 

Strengthspresent within the organization that support the planned change process.

 

· Co-workers knowledgeable of the ACA

· Strong unit manage supportive of project

· Robust organization reputation

 

Weaknessespresent within the organization that could be barriers or challenges to the planned change process.

 

· Chief medical officer unreceptive to change

· Weak internal communication process

· Cash flow problems

· Poor organizational morale

  Opportunities

· The ACA requires the Hospital Readmissions Reductions Program

· Loyal customers

· Protect hospital income

 

 

 

 

 

Threats

· Failure to meet discharge readmission rates mandated will result in loss of income.

· Other organizations have decreased discharge readmission rates.

· Loss of income could result in employee lay offs

 

Financial Implications of the Capstone Project

 

 

 

· What is the cost of the project to the organization and the patient?

· Is there any potential income that may result from the planned change?

· Will the potential income from the planned change be more than the cost of the project?

· What is the cost-savings to the patient?

 

External Influencing Factors-any factors external to the organization that influence the project. External factors will vary from project to project.

 

External stakeholder engagement and support

· Patients, community members, collaborative partners, businesses, fellow healthcare agencies, and others

· Collaboration with stakeholders should occur early in the process, and be maintained throughout the planned change process

Evidence-based, best practice standards

· Evidence-based best practice standards should drive policy and protocol at the point of healthcare delivery

· Example-Evidence-based protocol for treatment of emerging infectious disease

 

Accreditation mandates

· Accreditation bodies such as (The Joint commission) should drive policy, protocol, and practice within healthcare organizations

· Example-National Patient Safety Goals

 

Federal or state legislative/health policy mandates

· Healthcare legislation will drive healthcare policies, protocol, and practices

· Examples-Patient Protection and Affordable Care Act guidelines

 

Third party reimbursement regulations

· As healthcare changes, third party reimbursement policies have increased in complexity and specificity

· Example-30 day readmission penalties

 

External quality directives and benchmarking

· External quality metrics are powerful forces driving change within healthcare organizations

· Examples- HCAHPS, Core Measures, the Value-Based Purchasing Program through Centers for Medicare and Medicaid Services (CMS), and Accountable Care Organizational practices

 

SMART Patient-focused Outcome statement for the capstone project

 

 
 

Evaluation plan for the capstone outcome

(Patient outcome)

 

 

 

 

 

 

 

 

References

Impacting Factors Tool

Instructions: Use this tool to document your assessment of the factors impacting the capstone project. Be sure to cite and reference necessary sources according to APA format, using the last page for your reference list.

Name: ______________________________________________________________________

 

 

Stakeholder Identification and Engagement Strategies to Secure Support

 

 

 

 
 

SWOT Analysis

 

 

 

Strengths

 

 

 

 

 

 

Weaknesses
  Opportunities

 

 

 

 

 

 

Threats
 

Financial Implications of the Capstone Project

 

 

 
External Influencing Factors  

 

 

 

 

 

 

 

Outcome statement for the capstone project

 

 
 

Evaluation plan for the capstone outcome

 

 

 

References

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