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Prescribing in nursing and pharm


  • pg 1
									      Professions &
prescribing: insights from
   nursing & pharmacy
            Paul Bissell
           Public Health
       University of Sheffield
Medical sociologist / worked in pharmacy for over 10 years
Numerous evaluations community pharmacy practice:
  Advice-giving in pharmacy
  Lay and professional perspectives on risk of non-prescription
  Pharmacy supply of emergency hormonal contraception (EHC)
  Public health and pharmacy
  Social capital, inequalities and pharmacy
  Ethical dilemmas in community pharmacy
  Medicines management in community pharmacy
  Evaluation of supplementary prescribing in nursing and
Nursing & pharmacy professions both
make claim to be rightful heirs to non
medical prescribing.
Provide contrasting & overlapping insights
into sociology of professions / continuing
dominance of medical profession around
medicines usage.
Context for non-medical prescribing:
   power of medical profession
 “Doctors have held a unique position of
 power over prescribed medications for
 some years, a role that has brought with it
 the control of the scope of practice of other
 health professionals. It is likely that some
 will be reluctant to abandon it.” (Baird
 2000: 454)
Context for non-medical prescribing:
   power of medical profession
 “The medical profession has an almost
 exclusive right to prescribe medicines but
 this right is being challenged by…other
 health professions. It is argued that in
 British General Practice, prescribing is a
 battle ground on which the cause of
 clinical autonomy is defended.” (Britten
         Role of professions
Classic theme in medical sociology.
Friedson‟s „Profession of Medicine‟:
   medical power rests on autonomy over its
    own work activities and
   dominance / control over the work of others in
    the health care division of labour.
        Medical Dominance
“organised autonomy is not merely freedom from
the competition or regulation of other workers,
but in the case of such a profession as
medicine…it is also a freedom to regulate other
occupations. Where we find one occupation with
organised autonomy in a division of labour, it
dominates the others. Immune from legitimate
regulation or evaluation from other occupations,
it can legitimately evaluate the work of others.
By its position in the division of labour we can
designate it as a dominant profession”
(Friedson 1988:369).
         Medical Dominance
Last 30 years various arguments about
decline of medical power:
   Proleterianization: clinical freedom under
    threat from state / HMOs
   Deprofessionalisation: rise of assertive
    patients / narrowing of knowledge gap
Nancarrow & Borthwick (2005) discuss the
fluid nature of professional boundaries in
health care
           Medical Dominance
A consensus that medical power is being challenged, but
not necessarily eroded:
   Internal stratification within medical profession
   Cost awareness & containment: managerialism/ audit /
    clinical governance
   Greater scrutiny & regulation as a result of medical errors /
   Consumerism / lay knowledge /greater assertiveness by
   Professionalisation and availability of CAM
   Lay scepticism towards expert systems more generally
   Boundary encroachment from other health professionals
    (eg. prescribing and medicines management nursing and
Prescribing & medicines management in
         nursing and pharmacy
 General consensus about a challenge to, if not an
 erosion of medical power.
 How has the medical profession reacted to nurse and
 pharmacist prescribing / medicines management roles?
 Has this translated into enhanced status for nursing and
 pharmacy as a result of involvement in prescribing /
 medicines management tasks?
 What are the implications for nursing and pharmacy
Nurse Prescribing - overview
Development & reaction to nurse
prescribing in the UK and US.
Different experiences and responses by
medical profession in UK and US.
Evidence of considerable concern from the
medical profession.
          Nurse Prescribing

UK - able to carry out both Independent and
Supplementary prescribing.
Independent prescribing began in 1994 almost
Roots in DN – diagnosis requiring „rubber stamp‟ /
geographical distance from doctors require to sign
/ improvements in access.
Strong political support for prescribing role from
RCN – alliances with BMA & RPSGB / stressed
partnership model.
Push for private members bill (1992 Medicinal
Products: Prescription by Nurses etc Act).
          Nurse Prescribing
Conservative government concerned about cost.
June Crown appointed to carry out review of non
medical prescribing.
Series of pilot sites set up – rise of independent
prescribing (from limited formulary)
Pace of change speeded up post Labour victory
Extended Independent Nurse Prescribing from
Dependent, renamed supplementary prescribing
(via Clinical Management Plan) implemented.
 Nurse Prescribing - responses

Numerous (HSR) studies, claiming nurse
prescribing viewed positively by patients, is cost
effective, is (viewed as) safe, improves access
and does not waste doctors time.
Jones - „irrefutable proof‟ that nurse prescribing
was working on every criteria of safety, costs
and effectiveness.
By 2005 – prescribing from whole formulary was
announced (for both nurses and pharmacists) by
Sec of State.
Nurse prescribing – concerns from
        within profession
Lack / absence of formal supervision for nurse prescribers.
Lack of incentives to assist with mentoring.
Concern that it is driven by medical shortages / to reduce junior
doctors hours / size of medical budget.
Many nurses not prescribing despite completing training.
Concern that nursing becomes medicalized / looses identity as a
„caring profession‟.
Aidroos (2002) – „offer and drug and depart‟ service.
Will nurses be held to the same standards of care as other health
Do nurses have choice about whether to prescribe – evidence
that employers alter job descriptions to include prescribing.
Considerable scope to develop a sociological research agenda in
these areas.
Nurse prescribing – concerns from
       medical profession
BMA (2002) – „training nurses get is nothing like sufficient and will
not give them the clinical knowledge they need to prescribe these
Nurse prescribing - „a dangerous uncontrolled experiment‟ (Horton
2002) - also refers to prescribing entailing a loss of nurses identity.
Criticism of nursing – seen through lens of professional attributes.
Others more cautiously optimistic about nurse prescribing (Avery
and Pringle 2005).
Concern about speed of change / availability of mentoring from GP /
doctor / availability of role.
Medical press (eg Pulse) maintaining pressure & surveillance over
nurse prescribing.
Numerous concerns about pharmacology & therapeutics training for
    Safety & nurse prescribing
Systematic review of safety of nurse (supplementary)
Most published papers not based on empirical research /
focus on adequacy of nurses training, knowledge &
Review shows that doctors believe that Clinical
Management Plan allows them to retain power / provides
a framework for guiding decisions.
Little empirical evidence that nurse prescribing is
Concerns tempered by awareness of scope / scale of
nurse prescribing in England.
        Overview of PACT data
Year                           Item volume    Net ingredient cost
2004                           3.5 million    £52.2 million
2005                           4 million      £58.9 million
2006                           6.3 million    £79.3 million
2007 (to end of September)     6.8 million    £79.5 million

Year                            Item volume   Net ingredient cost
2004                            2706          £25,348
2005                            11,458        £96,846
2006                            31,052        £278,634
2007 (to end of September)      44,318        £332,320
                Nurse PACT Data
                                         Nurse Prescribing 2006
    Nurse Prescribing 2004-2006

7                                                              Appliances
                                                Other 15%      7%
6                                                                           CNS 9%

                             2004   Obs, Gynae
4                                   and UTI 4%
                             2005                                           6%
                             2006    Skin 12%
1                                       Infections                    Dressings
                                        10%                           32%
         Item volume                                 Cardio-
                                                     vascular 5%
            Nurse prescribing
UK - establishing prescribing rights for nurses has
involved some conflict with the medical profession.
Not clear that supp rx based around CMP enhances
CMP provides reassurance for doctors.
Maintains status divisions between supp & independent
Indeterminacy / technicality ratio – supp rx based around
CMP / maintains status hierarchies.
Diagnosis / independent prescribing may result in rather
more conflict.
Different to situation in the US.
     Nurse prescribing in US
Development of nurse prescribing resulted
in much more opposition in the US.
Nurse prescribing grew out of nurse
practitioner role in paediatrics / response
to „thin provision of care‟ in rural areas.
Creation of „negative formularies‟ for
nurses / negotiation of independent
prescribing in most states for NPs.
      Nurse prescribing in US
Mundinger et al (2000) „combination of authority
to prescribe drugs, direct reimbursement from
most payers and hospital admitting privileges
creates a situation in which NPs and primary
care physicians can have equivalent
NPs reimbursed at same rate as physicians in
some states.
Fennell argues „inherent in the physician and
pharmacist opposition to nurse midwives
prescribing is…an interest in their own economic
     Nurse prescribing in US
Byrne & Helman (2002) – anti-competitive
practices of health plans where consumers
are instructed to use mail order/internet
pharmacy services, many of which refuse
to accept NPs prescription.
Chen-Scarabelli (2002) – „various state
medical associations lobby against nurse
practitioners in a an attempt to maintain
monopoly over health care management‟.
     Nurse prescribing in US
Edgley et al – “federal state‟s reactive
stance has opened the way for overt
conflict between the professions as they
fight it out over territory, rights and
Professions‟ responses to threats &
opportunities depends on organisational
Nurses successfully developed prescribing role.
Concerns from within nursing and from medical
Appears to be significantly more conflict in the
US than UK.
Medical profession able to mobilise arguments
about appropriateness of nurse training, despite
lack of evidence about risks / dangers /
inappropriate prescribing / consideration of type
of prescribing being undertaken.
Likely that IP will evoke more conflict than SP.
Pharmacists’ roles in medicines
  management & prescribing
Pharmacy - very different history & response to
challenges of non medical prescribing.
Much slower engagement with prescribing agenda.
IP only just getting started / several years of SP.
Professional development shaped by commercial &
organisational environment (community) pharmacy
operates in.
Significant barriers to (community) pharmacists
developing role in this area.
Must overcome these barriers AND deal with potential
opposition from medical profession vis a vis IP and SP.
     Pharmacist prescribing?
Eaton and Webb (1979) – interviewing
educators and policy makers:
“…I would draw the line at prescribing – the
pharmacist isn‟t trained to prescribe
“Well really I think lines may be drawn in
terms of the medical degree…But they
(pharmacists) will never be involved in
prescribing, at least in Britain, unless they
have a medical degree. You can‟t sign a
prescription which somebody will honour.”
Community Pharmacy – recent history

Up to mid C20th legitimacy based on expertise in
compounding / producing proprietary medicines.
  Original pack dispensing from 1960s onwards forced
   loss of role
  Pharmacy has long history of links with commerce /
   „petit bourgeoisie‟.
  Ambiguous relationship with the NHS – private provider
   in socialised system.
Community pharmacies seen as „dispensing‟ factories –
considerable professional dissatisfaction.
Pharmacists „over qualified & under utilised‟ (Eaton & Webb
1979) – de-skilled.
New roles for pharmacists – essentially a quest for survival
(Edmunds & Calnan 2001).
    Pharmacy & sociology of the
Denzin and Mettlin (1968) – pharmacy
viewed as a case of „Incomplete
   Pharmacy lacked control over the „social
    object‟ of practice - the medicine.
   Pharmacists guided by commercial interests
    at odds with the altruistic, service orientation
    of a profession.
   Essentially, a highly damaging critique /
    retains potency.
    Pharmacy & sociology of the
Dingwall & Wilson (1995)
  Critique of Denzin & Mettlin (1968) position

  Other professions (e.g lawyers) associated with

   commerce, does not undermine professional status.
  Pharmacists transform objects (drugs – medicines)

   and have a (Foucauldian inspired) role in surveillance
   around medicines usage.
  Hibbert et al (2002) – weak role over medicines

   surveillance; protocol driven; role undermined by „lay
   expertise‟ / consumerism.
  Turner (1995) refers to pharmacy as tainted by „petite

   bourgeoisie‟ image.
   Pharmacy & sociology of the
Pharmacists increasingly „corporatised‟ – increasingly
employees rather than independent practitioners.
Key decisions not taken by pharmacists (tensions
between superintendents & marketing departments) /
„de-pharmacisation‟ of chains / multiples.
Lack autonomy over work practises / boundary
encroachment from others.
Small profession (45 000 registered pharmacists – split
between hospital and community.
Considerable dissatisfaction with working practises in
community pharmacy.
  Re-professionalization project.
Plethora of policy documents – PIANA, Choosing Health
Through Pharmacy, Pharmacy in the New NHS…
Some new roles identified:
  smoking cessation,


  supervised methadone

  minor ailments schemes

  Supplying emergency contraception

  Chlamydia screening

NHS contractual framework for pharmacy – essential,
advanced and enhanced.
Prescribing and medicines management…
  Re-professionalization project.
Continuing issues in community pharmacy‟s re-
professionalisation project:
  Commercial environment in which pharmacy is
  Limited autonomy as employees

  Patient doubts about appropriateness of community
   pharmacy as a site for advice / medicines
   management / prescribing?
  Isolation from other professions / policy arena

  Subordination
    Community Pharmacy Medicines
     Management Project (CPMMP)

Project developed / implemented by the Pharmaceutical
Services Negotiating Committee (PSNC)
Funded by DoH (2001-2004)
Aim: to evaluate the introduction of a community
pharmacy led medicines management service for
patients with coronary heart disease (CHD)
Evaluated by independent research team using RCT &
qualitative research:
   University of Aberdeen
   University of Nottingham
   Keele University
                          The CPMMP
                                  Study Protocol

                          9 localities picked to particpate:
                            Nantwich, Lichfield, Walsall
                          Poole, Portsmouth, Southwark,
                           Shipley, N. Tyneside, Salford

   GP in each area           Pharmacists in each area               Patients invited to
 invited to participate        invited to participate          particpate from GP surgery
READ code search to              Have to complete              Randomised to intervention
identify CHD patients              CHD training                or control group (2:1) ratio

Review pharmacist's          Pharmacist receives                     Control Group
  recommendations         summary of clinical information          receive medication
& action if appropriate       from audit clerk for                    in usual way
                             intervention patients

                               Intervention Group
                            Receive medication review
                           from pharmacist & follow-up
                                during 12 months

                              Medication +/or lifestyle
                             recommendations made
                          Discussed with patient and GP
          Results-% appropriateness
                  Intervention   Intervention   Control    Control    P-value
                    Baseline      Follow up     Baselin   Follow-up
                      82             80          76         78          *
Aspirin-related       95             94          91         93        0.24
Target                59             58          57         55        1.00
Statin                73             79          68         77          *
BP                    47             49          43         47        0.49
Qualitative interviews and focus groups with
doctors, pharmacists and patients sheds
considerable light on ways in which the doctors
and pharmacists are working together?
Informs a sociology of pharmacy.
    Pharmacists views about
    medicines management
Very positive about service:

 “It‟s wonderful to be able to talk to people”
Better patient care:

   “We‟re getting closer to some of the patients because
    they think…feel that you‟re taking more of an interest in
    them rather than oh, another customer!” (P11/FG3)
Using clinical skills:
   “It certainly is an extension of our role and a very
    worthwhile one, actually using our clinical skills for a
    change.” (P16/FG4)
Pharmacists’ concerns: GPs’ perceptions
      of their subordinate status

    “We work as a team but they (GP) think they‟re the
      upper class; we are the lower class you know”

    “They sort of think of…they still think that a
      pharmacist is a class down, like you know you
      think of a shopkeeper.” (P14/FG7)

    “Because they‟re not used to having their judgement
      questioned…Not by someone that they perceive
      as being a shopkeeper.” (P12/FG4)
Pharmacists’ concerns: GPs feeling
 “I think it‟s because they feel threatened; it‟s human
    nature isn‟t it? You are impinging on their territory.”

 “They might feel their opinion is being challenged, that
   they are being checked upon, or whatever because I
   suppose they are not used to it. It is a new thing for
   them really to have someone who is looking at the
   notes they have done themselves.” (P09/FG2)
       Commerce & Pharmacy
  GPs concerned that community pharmacists
  advice influenced by commercial factors

“The difficulty I have really is trying to be certain
  that their advice is not commercially related”

  Resulted in GPs being suspicious of the
  clinical advice they received from community
  Access to Medical Records

“ I think the whole area then that opens up is all
   the areas of confidentiality and people who
   are not actually part of the GP primary care
   team, who have access to confidential
   medical records, which may include so and
   so is having an affair with so and so, who
   might happen to be the pharmacists
   neighbour you know. It may not, it‟s a most
   unlikely scenario but our duty first and
   foremost is to all our patients is
   confidentiality.” (GP15)
    Pharmacists Changing Patients
Concerns about whether it was appropriate for
community pharmacists to change patient‟s
   Do community pharmacists know patients well
    enough to undertake this service?
   Pharmacists involvement could cause fragmentation
    over patient care & responsibility
   Patients could become confused if more than one
    person had responsibility for medication
   Pharmacists lack access to medical records when
    undertaking medicines management role
 Pharmacists Changing Patients
“ I mean I think getting medication right is
   quite complicated and it depends on
   quite a lot of medical historical
   information and unless they have got
   the whole set of notes and they are
   sitting down with the patient and got to
   know them over a period of time they
   can‟t do that” (GP15)
Likely to be highly relevant to prescribing.
Reasons for GPs’ Concerns
“Professional boundaries”
“Threatening…challenging management
and criticism”
“The whole area opens up areas of
confidentiality and people who are not
actually part of the primary care team”
Strong support for CPMMP in some areas,
GPs highlighted many concerns:
   Community pharmacist‟s links with commerce
   Some resistance to pharmacists undertaking new
    roles & boundary encroachment
   Some resistance to community pharmacists
    having access to patient‟s medical records
   Distance from patients - concerns that
    pharmacists do not possess a detailed knowledge
    of the patient & clinical histories
   Isolation from medical / nursing professions and
    primary care more generally.
Medicines Management: A challenge
      to medical dominance?
Issues identified by Denzin & Mettlin (1968) still relevant –
commerce / altruism / motivation.
Strong discourse around community pharmacy‟s subordinate
position in health care division of labour.
Distance from patients „everyday‟ care.
GPs able to mobilise powerful arguments against pharmacists
involvement. Eg commerce, access to records, confidentiality,
knowledge of patient.
Able to name / identify roles for pharmacists eg. compliance /
repeat dispensing but NOT changing medication.
Pharmacists collude to re-produce and sustain their own
subordinate status. Eg. reference to „shops‟; deference to GPs.
Medicines Management: patients views

 Patients‟ views similar to GPs assessments of
 pharmacists involved.
 Cautiously welcoming „talking to pharmacists‟
 But anxious about them making recommendations
 about treatment / changing medication.
 Concerns about the commercial environment / strong
 awareness of subordinate position of pharmacy.
Medicines Management: patients views

 Commercial influences:

 “I‟m just not sure I‟m happy about it at all. I enjoyed
 talking to him, that wasn‟t the problem. It‟s just at the
 back of your mind, is it me, or is it a bit daft, you
 wonder about, well, you wonder about the drugs
 companies and all that, and all those promotions in
 the shop…I came home from it, and we were talking,
 I said, is it the kind of place they should be doing this
 kind of thing?” (R5)
Medicines Management: patients views

 Subordinate position:

 “The pharmacists don‟t diagnose, don‟t they? The
 doctors do that. They put you on the treatment and
 the pharmacist just gives you it.”

 „Because you look at most prescriptions…It says if
 you develop any of the following consult your GP.
 And this is from the chemical company. They don‟t
 say go to the pharmacist. They say go to the doctor.‟
       Subordination & isolation

Cooper‟s research around ethical loneliness of
Draws on qualitative research with pharmacists:

Subordinate position:
“I tend to feel that when I get a prescription, coming
back to your point, that it‟s the doctors responsibility
ultimately and that I‟m just a tool of the doctor really.
I‟m not happy with it, I‟m passing the buck and not
accepting the responsibility that I should be taking.”
       Subordination & isolation

“In a way we are isolated as pharmacists and we
haven‟t got anyone to chat to, to ask about things, to
find out what other pharmacists think”.

“We‟re all islands and we‟re all competing against
each other […] The only time when you come into
contact with another pharmacist is when there‟s a
conflict with something or when you want to borrow

Habermas / Mead (discourse ethics) – loneliness /
isolation may be ethically problematic for
A sociologically informed research
      agenda for pharmacy
Commerce, altruism, isolation, subordination
retain some force.
Nancarrow & Borthwick (2005) – not clear
that taking on new roles results in enhanced
Moreover – „no examples of role changes
that have removed the attributes that are
associated with the professional labels.‟
Community pharmacy remains a site tainted
by commerce, isolation, subordination.
To develop, pharmacists leave the
commercial environment / undertake
professional journeys / narratives of change.
Prescribing & medical dominance?

Britten (2001:478): Prescribing and the defence of
clinical autonomy:
“The medical profession has an almost exclusive
right to prescribe medicines, but this right is being
challenged by the State, patients and other health
care professionals…These changes do not yet
support the thesis of proletarianization [or
deprofessionalization] as the medical profession
continues to dominate the clinical agenda and
responsibilities of other health care workers.”

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