Nurse prescribing in family planning.

A true story Recently a friend of mine (who was also a family planning patient for a while) forgot to take her combined oral contraceptive pill. As a busy detective sergeant in the Metropolitan police and scheduled to work a long weekend, she knew she would not have enough time to go home to take her pill before it became ‘overdue’. Both she and her partner were well motivated to use condoms if necessary, but her big worry was the blinding headaches she got in the pill-free week. So she phoned me to ask: “Where could she get three Mercilon® pills – and quick?” As she was just stepping off the Tube in central London, I suggested she pop into a pharmacy chain and I could talk to the pharmacist. “Please could my friend possibly have a pack of pills?” “No – doctor’s prescription required.” “I am her family planning nurse, I can vouch it is safe and proper for her to have them.” “No.” “But I have been prescribing them for her for the last 2 years.” “No, you’re not a doctor – and anyway, nurses don’t prescribe drugs.” “But what about that bit in the British National Formulary (BNF) about emergency prescribing?” “Contraceptive pill is not an emergency.” Click, the phone went dead. The pharmacist was not interested in my friend or my opinion. A pack of Mercilon probably only retails at around £3.50 so it didn’t represent a huge sales loss to the store, and as far as the guy was concerned it was only a ditzy woman who’d forgotten her pill. Not ‘proper medicine’, like insulin or digoxin. Not a ‘doctor’ giving life-saving medical advice. What an insult, I thought! No, not the bit about the ditzy forgetful woman – the rude bit about “nurses don’t prescribe”! I was shocked. As far back in my career as I can remember nurses have prescribed medication, albeit rather informally. As a student nurse working nights in the early 1980s I can remember phoning the night nursing officer to come round to the ward to administer nitrazepam to a restless patient requesting something to help them sleep. In the morning the sleepy house officer would happily sign-up the ‘once only’ medication, not for a minute considering challenging the wisdom of a nursing officer at least 40 years his senior. Paracetamol seemed to be kept permanently in the pocket of various ward sisters, to be given carefully and with due consideration but nevertheless unprescribed (“You can buy it by the bucket at Boots!”). Later on I discovered varying degrees of collaborative multidisciplinary prescribing on surgical ward rounds: “Mrs Smith is still in a lot of post-op pain, Doctor.” “What do you think she would like, Sister?” “I thought a couple of Distalgesics® right now with a Temgesic® to take her through the night?” “Excellent Sister, I was thinking just the same – keep up the good work and don’t forget the Eusol and paraffin soaks!” Protocols and PGDs More recently, developments in nursing have seen the dawn of protocols and patient group directions (PGDs). For the uninitiated, these tedious pieces of paperwork describe in excruciating detail exactly how, when, where and why a particular drug may be given to a patient by a registered nurse, in the absence of a doctor. Frequently these drugs are also available to the general public, over the counter without a doctor’s prescription. How many of you work with PGDs for the administration of emergency contraception, for clotrimazole pessaries for the treatment of vaginal candida, or for ibuprofen [Indication: simple analgesia post-intrauterine device (IUD) insertion – no kidding!]? It makes me want to weep, thinking of the time, money and effort expended by various nursing colleagues in writing these weighty tomes. Page after page of drivel, typed by some weary fool in the vain belief they will be ‘covered’ in the event of something going amiss. At the very least I find PGDs patronising, and at worst I suspect (although quite clearly cannot prove) they are there to allow nurses to carry out the job of a doctor, when the Trust won’t budget for appropriate levels of medical staff. Some may argue protocols and PGDs allow nurses to work to their full potential, being autonomous practitioners, meeting the holistic individual needs of their patients and clients. I say: “Oh please, spare me”! Nurses are being led to believe this by those who think they are doing us a favour, but in fact we are doing them the favour. In family planning many of us have been issuing hormonal medication for so long we know those pills inside out. Tell me a foil colour and I’ll tell you which pill the woman is taking. We know the difference between Femodene® and Minulet®. We know whether the green one is Loestrin® 20 or 30. Quite clearly there is more to prescribing a contraceptive than knowing whether there are pretty flowers on the box, but a two inch-thick document that basically says if there is no change in the medical history and her blood pressure is within normal limits then the nurse can give the woman another 3 months’ supply is not exactly pushing the boundaries of clinical practice and challenging the nursing orthodoxy.