In the UK, there are 54, nurse and midwife non-medical prescribers NMPs who improve patient access to consultation and medication Morris and Grimmer, , and over 19, nurse independent prescribers and supplementary prescribers who improve treatment and patient safety Royal College of Nursing, Independent prescribers can prescribe controlled drugs, including opioids, methadone and buprenorphine Public Health England, Some NMPs may feel pressured into taking a wider responsibility for prescribing and signing repeat prescriptions for drugs, but may not receive adequate support from line management Maddox et al, Opioid dependence is a chronic relapsing disorder associated with opioid misuse, which resulted in 51, deaths in — up from 18, deaths in PHE, Its characteristics include:.
Opioid dependence is diagnosed through consultation, history taking, physical examination and urinalysis opiate metabolites in urine Praveen et al, The primary intervention is controlled drugs — such as methadone and buprenorphine — prescribed under the Drug Misuse Act Hser et al, in primary care, community services, prisons, and substance misuse and mental health settings PHE, Methadone is cost-effective and can reduce injecting behaviour Soyka, Treatment regimens involve slowly decreasing the dosage over time, which helps reduce the intensity of opiod withdrawal symptoms Beck et al, , including:.
Methadone can result in adverse reactions see Box 1 so NMPs must be cautious when prescribing controlled drugs such as this, due to the side-effects and potential risks of toxicity and diversion selling the medication, storing it or giving it to friends NICE, Buprenorphine is a first-line treatment for patients with opioid dependence and heart disease, as there are no adverse reactions relating to heart problems Fareed et al, Other medications may be considered, such as lofexidine, antipsychotics, antidepressants and benzodiazepines for an opioid detoxification Department of Health, Opioid dependence is also associated with risks of overdose, death and infection with blood-borne viruses such as HIV, hepatitis B and hepatitis C.
Therefore, there is a need for harm minimisation advice on safer sex, needle exchange and immunisation World Health Organization, The decision to prescribe should include a discussion with colleagues in the multidisciplinary team and be supported by clinical documentation PHE, This encourages NMPs to review the assessment and ensure an appropriate clinical judgement has been made Morris and Grimmer, Patient safety must remain paramount in the consultation Maddox et al, There are several models of consultation with systematic structures and approaches that are relevant to specialist addiction, which includes opioid addiction Table 1, attached.
The Calgary-Cambridge model is brief and systematic, provides a structure and helps to build a relationship with patients Courtenay, In addition, it can be applied in all clinical settings for NMPs and the steps identified are already used in day-to-day communication Kessler et al, The Disease Illness Model integrates the two frameworks to initiate planning and explain the consultation to the patient Denness, , but it lacks a holistic approach and does not consider issues such as concordance with treatment Bowskill et al, Communication difficulties between NMPs and patients — including a lack of documentation, reporting and adherence to protocol and guidance — are strong contributors to medical errors Maddox et al, Other models, such as that developed by Weiner , place emphasis on basic initiation by the sender and interpretation by the receiver.
Communication can improve negotiations among medical and nursing colleagues and the patient relationship, as well as helping to resolve potential conflicts in consultation Denness, Medication errors can stem from the wrong drug, dose, route, frequency or quantity Morris and Grimmer, , while poor communication can lead to medications not being taken as intended Nuttall, A lack of monitoring and follow-up can also lead to adverse drug reactions.
NMPs should remember that legal responsibility remains with the prescriber who signs the prescription Petty, Future studies should explore consultation models in NMP practice and how they affect the treatment of specialist addictions. Poor consultation skills are associated with poor communication, medication errors and poor decision-making for patients Maddox et al, , but NMPs can improve outcomes by using consultation models to guide their practice. NMPs must be aware of their own professional, legal and ethical accountability when caring for patients with opioid dependence NMC, , and understand that not using a consultation model can encourage poor decision making and consultation structure, thereby jeopardising patient safety Carey and Stenner, Beck T et al Maintenance treatment for opioid dependence with slow-release oral morphine: a randomized cross-over, non-inferiority study versus methadone.
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Trustworthiness or methodological soundness was important to this study. Trustworthiness was established based on the framework presented by Lincoln and Guba [ 50 ], being criteria of credibility, transferability, dependability, and confirmability. Figure 3. The progress through the hermeneutic dialectic circle for a stakeholder group.
The final construction emerges, and the circle is complete. The circle should continue until all available participants have been included. Figure 4 shows a summary of all the participants at each stage, and Figure 3 shows a summary of the developing construction. The results from the concensus meeting multidisciplinary focus group are discussed below. The findings of the study reassuringly revealed much common ground but also some clear differences of opinion.
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It was encouraging and, perhaps, surprising given the inconsistency in practice to note that no major objection to the concept of NMP existed from the medical staff, but all felt the right model was important. In terms of the optimal model for chemotherapy services, all agreed that an alternative cycle model concurrent with the medical team was the preferred option.
It was unacceptable to the nurses to develop a model, where the doctors prescribed the treatment but the nurses assessed suitability to receive the treatment. Nurses wanted the full autonomy of NMP. This proposal means the patient would alternate between the doctor and the nurse for each visit for chemotherapy, i.
Indeed, one doctor said. I am all in favour of specialist nurse services especially in chemotherapy but there must be good communication.
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Figure 4. A summary of the individual claims concerns and issues of all the professional groups including the agreed construction and outcome at concensus meeting. Whilst this model was agreed through this dialogue process, it was clearly noted that those present could not dictate practice to those not present. I can have a view on how others practice but I cannot make it happen.
And also. What we need is a local champion, doctor, I mean, to support us —Nurse. Whilst it was fairly straightforward to get executive support for NMP, it was thought inappropriate to exercise this high authority in insisting practice models change. A better strategy was to win over medical consultants by demonstrating the value of NMP to their service and by engaging them in the process as medical supervisors.
However, that said it was difficult to demonstrate value when access to patients is restricted. This was highlighted further in that all agreed to the model for the service but implementation of the model would be for individual doctors to agree. This powerful position could yet still prevent the service moving forward and allow the current inconsistent service to carry on.
It was thought essential within this model to have a communication debrief after each clinic with all present to discuss decisions, queries, and patient progress. Whilst there was agreement that the above should be the optimal model, it was also agreed that nurses were the obvious choice to extend their role.
From the previous dialogue with the pharmacist and an insider knowledge of their desire to practice in chemotherapy clinic, this was a difficult message to hear for the pharmacist present though no objections were voiced at the time. The open formulary had been contentious throughout the previous dialogue. This poles apart view was explained to the group that evoked strong reaction. I think given the extreme, well I think its extreme, response, regulatory response, we have seen to the isolated insanity of Shipman it is bizarre to permit a huge body of people who have been subject to substantially less pharmacologic training, the authority to prescribe those drugs —Doctor.
In addition, a nurse stated. I feel insulted by that view and to think anyone would suggest I might be cavalier and start managing conditions I know nothing about is unbelievable. I am a professional and have my code of conduct to guide me. This was a difficult issue to resolve, as the nurses and pharmacists all believed they would only prescribe within their competence, as would the medical staff, yet creating a formal boundary as in a local formulary was seen as professionally abhorrent and sectarian. Why should we be treated any differently? Medical staff are not asked to work to a formulary, why should we.
I will be accountable —Nurse. The above two quotes illustrate the view of all the nurses present but are interesting as they represent a changed view from the nurse focus group when their own construction was agreed. At that point, a year earlier, nurses had no objection to a local formulary in order to advance practice.
Now, all nurses present resented the restrictions imposed whilst still being clear they would only prescribe within their boundaries. The MDT is a multidisciplinary team meeting where all involved in the care of an individual attend to discuss the treatment plan and make decisions regarding the care of every patient. They are cancer site specific, and, generally, patients are discussed only once prior to beginning chemotherapy. In order to be involved in prescribing chemotherapy, MDT attendance was seen as vital for one particular doctor and agreement could not be reached through the medical focus group.
This doctor was not present at the consensus meeting but had asked to meet after the meeting to add in his thoughts. The doctor in question was clear to say, it was not his view that he would necessarily lack confidence in a nurse-led service but he wanted to avoid anyone of his team working in isolation. The nurses and pharmacists did not have a strong view about this and wanted to be part of a team which the concurrent model above facilitates.
They did not see benefit in attending the MDT. It also became clear that the medical staff present had a little knowledge of what NMP activity took place outside their own clinic. Indeed, this lack of awareness of other NMP activity was cited by the author as one of the reasons for the ad hoc nature of the service. In hindsight, correcting the lack of awareness was clearly within our gift. Describing their own experience of MDTs those present felt, there was a little point to MDT attendance as at the point the decision is made to refer to chemotherapy the patient has yet to be seen by anyone from cancer care, and therefore their suitability for chemotherapy is unknown.
Clearly, no one present could articulate a positive view in attending the MDT, therefore a follow-up discussion with the doctor who held the view that MDT attendance was vital helped clarify his position.
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He conceded his view was unique and he reiterated his point that those involved in treatment must be part of the team but also recognised the view of others. A summary document of training requirements for NMP was circulated prior to the consensus meeting as it was clearly recognised through phase 1 and 2 medical colleagues were unclear about the programme.
Questions were asked regarding the governance arrangements within the Trust which reassured those present. The medical staff asked about the medical supervisor role and were reassured that they had the opportunity to work with trainees who would potentially be prescribing chemotherapy. In addition, the group was informed about the single competency framework in development for all prescribing professionals, which offered some reassurance [ 60 ].
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It was agreed by all involved that NMPs should have an annual assessment of competence. Whilst this is not currently required for medical staff, the same reaction of horror from the nurses and pharmacists was not present for this initiative as for the local formulary. All agreed that it was good clinical practice in a changing health care. Important to this research was that the process should generate change. One of the concerns was that despite this research process and prolonged engagement with stakeholders of the service, the practice setting will remain the same.
Medical leadership within a team context is standard in chemotherapy, and nurses and pharmacists need to work within this culture. As stated by Buckley et al [ 15 ], the future development of any NMP is clearly dependant on well-developed relationships with medical consultants without which the service will remain static. Alongside this, nurses and pharmacists need to be very clear what core values underpin practice and should look to ways to demonstrate their contribution in a meaningful way.
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As intimated by Goswell and Siefers [ 43 ] and Crew [ 44 ], maximizing the benefits of a flexible workforce will only occur if there is transparency about the different professions contribution in a valuable and sustainable way. This is no easy task, as despite strengthening the standards of training for NMPs, some doctors still have concerns and misunderstandings about this role [ 24 , 62 ]. This view though is counterbalanced with extremely favourable outcomes from further studies in NMP [ 24 , 25 , 63 ].
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