Issues of Nurse Prescribing in the UK

Issues of Nurse Prescribing in the UK Introduction The changing face of the NHS is a topic of controversy and debate from the perspectives of professionals and policy makers. The last three decades have seen a transformation in nursing in the United Kingdom, and in the ways that nurses envisage themselves (McCartney et al, 1999). This transformation is only one symptom of a raft of policy changes which have affected the NHS. Evolution of nursing as a profession has seen them moving from being a group labelled the doctors’ handmaidens to a professional group with its own staunchly defended identity (McCartney et al, 1999). This new professionalism has also led to diverse developments and advancements in the role and functions of nurses, with increased autonomy and extended roles which could be viewed as encroachment on medical roles or as ideal management of an already skilled and knowledgeable workforce. As far back as 1986, the Cumberledge report raised the possibility of allowing community nurses to prescribe independently, and several years later the necessary legislation was initiated (McCartney et a, 1999). In 1997, the government established a review of prescribing, supply and administration of medicines, chaired by Dr June Crown (Stephenson, 2000). This became known as the crown report (DH, 1998). It was chiefly concerned with the supply and administration of medicines by group protocols (S tephenson, 2000). A group protocol could be described as a specific written instruction, drawn up locally by doctors and pharmacists, for the supply or administration of named medicines by other health professionals in an identified clinical situation (Stephenson, 2000). A number of authors supported this move and in particular, the ability for nurses to be able to prescribe medications for clients in certain circumstances. However, the implementation of this policy change has been neither uniform or timely. This paper will explore the policy context of the implementation of nurse prescribing, utilising a theoretical framework to examine the laggard nature of the change and the reasons why nurse prescribing remains unfinished business in the professional and policy arena. The theoretical framework used will be the Diffusion of Innovation theory, as defined by Rogers (1962, 1976). Diffusion of Innovation Rogers (1962, 1976) defines the diffusion process as the spread of a new idea from its source of invention or creation to its ultimate users or adopters. This could be considered the macro level of change assimilation or even awareness. However, the notion of diffusion of innovation is more than a macro concept, and Rogers (1962, 1976) further differentiates what he describes as the adoption process from the diffusion process in that the diffusion process occurs within society, as a group process; whereas, the adoption process is individual. In Rogers’ (1962, 1976) opinion, the adoption process is the mental process through which an individual passes from first hearing about an innovation to final adoption. The theoretical construct of chief concern here is that of macro level diffusion of a professional innovation. There are five stages in the Innovation-Decision Process as described by Rogers (1962, 1976) and these will be mapped against the literature below. First knowledge of innovation (Rogers, 1962, 1976). First knowledge of innovation could be pinpointed to the Cumberledge report in 1986, which was a report into community nursing, after which the issue was debated and discussed and entered into the theoretical arena in the healthcare professions and healthcare policy and governance in general. However, Jones (2004) cites the case of nurses who began to make a case for prescriptive authority in 1978. There is varying evidence of how diffuse this knowledge became at a societal and policy level and there is some evidence of widespread resistance in the medical and pharmaceutical professions (Jones, 2004). It is important to remember that for some critics, nurse prescribing does not necessarily constitute something entirely innovative. Nurses already perform a number of roles which require full knowledge of medications, but there may be issues about education and skill levels across nurses educated in different places (King, 2004). If there are questions already about nurses’ knowledge and ability around medications, then the preliminary debate about this issue (which extended over two decades) is understandable. Forming an attitude toward the innovation (Rogers, 1962, 1976) A number of attitudes towards this innovation are apparent in the literature. For example, Jones (2004) suggests that implementation of this innovation would be characterized by political machination, the need to construct an effective case, and deft manoeuvring within the corridors of power. This raises issues to do with the context within which the innovation takes place, as already discussed. Jones (2004) also alludes to the district nurses who presented a case in the 1970s, and the RCN who continued to press that case further. This also relates to Rogers’ (1962, 1976) description of some of the factors or prior conditions that affect the innovation-decision process, such as previous practice (which may influence the decision makers in a positive or a negative way), and the norms of the social systems in which the innovation is taking place. The firmly entrenched hierarchical norms of the NHS and healthcare systems in general could be viewed as the biggest hindrance to nurs e prescribing, and so forming an attitude towards the innovation, for all the key players within the system. A decision to adopt or reject (Rogers, 1962, 1976) The decision to adopt the innovation occurred piecemeal and somewhat sequentially in time. Jones (2004) states that it was after much initial scepticism and a good deal of negotiation that a tacit agreement between nursing, medicine and pharmacy was reached in 1988. Subsequently, the RCN wree able to cause the government to initiate the Crown report in 1989. However, there were limitations to this decision, in that it was restricted to health visitors and district nurses who would be able to prescribe by virtue of them having post registration qualifications that marked them as competent in this advanced field (Jones, 2004). Implementation of the new idea (Rogers, 1962, 1976). It is this stage which is the most problematic in relation to nurse prescribing, perhaps due to the nature of adoption across the wider NHS context. Nurse prescribing is sanctioned, but remains a locally differentiated policy with apparent piecemeal implementation. This could raise issues of quality and also the ability to evaluate the effects and impact of nurse prescribing at the macro level. Despite the adoption of the principle, there was a distinct lack of action in moving the agenda forward, and it was some time before the bill was passed through Parliament in 1992 (Jones, 2004). The literature shows that the legislation passed in 1992, and in 1994 nurse prescribing began in eight demonstration sites (Bates, 2002). Following this pilot, a national roll out of nurse prescribing began in 1998 (Bates, 2002). This, however, applied only to nurses with district nurse of health visitor qualifications working in the community and employed by an NHS Trust or GP (Bates, 2002). Confirmation of the decision. Confirmation of the decision can also be seen within the literature, in that in 1999 there was a review of prescribing, which then recommended that prescribing rights be extended to include other groups of nurses and other health professionals (Bates, 2002). Subsequent to this, the NHS Plan (2002) clearly supported the recommendations and it was posited that by 2004, nurses should be able to prescribe independently, or supply medicines in Patient Group directions in four areas: minor illness, minor injury, health promotion and palliative care, within the aegis of a Nurse Prescribing formulary (Bates, 2004). Bates (2004) stated that there were approximately 22000 nurse prescribers in the UK, 3000 of which were in Scotland (at the time of her article). This suggests that there is widespread confirmation of the decision through demonstrable changes in practice. It is also notable that nurse prescribing has further progressed towards supplementary nurse prescribing, which allows nurses a nd other health professionals to prescribe for a patient who has been through an initial assessment by a doctor, in accordance with a clinical management plan (NHS Scotland, 2002). It should be noted that prior conditions affect the innovation-decision process. Prior conditions include previous practice, felt needs/problems, innovativeness, and norms of the social systems (Rogers, 1962, 1976). Consequences of Innovations (Rogers, 1962, 1976). Any discussion of the innovation-decision process, must also consider the consequences or changes that can occur to a social system as a result of the adoption of an innovation. Rogers (1962, 1976) identifies three consequences or changes. Desirable versus undesirable consequences The primary purpose of nurse prescribing is to give maximum benefit to patients and the NHS, whilst also supporting quicker and more efficient access to healthcare while promoting a more flexible use of the skills of the existing workforce (Bates, 2002). This however could be a somewhat idealistic view of general nurse prescribing. While for many nurses it may enhance their ability to provide care, others may consider that it simply adds to their already onerous workload. There may also be ethical issues, perhaps through conflicts between personal, official and legal senses of duty for nurses, which could result in cognitive dissonance between their conceptual model of their nursing role and the new directives to extend this role in to a traditionally medical area of responsibility. Nolan et al (2001) in a study of mental health nurses’ perceptions of nurse prescribing found that most of their respondents felt that this would significantly improve clients’ access to medication, improve compliance, prevent relapse, and prove cost effective. However, the same respondents also felt that they may not have sufficient knowledge and skills to assume responsibility for prescribing (Nolan et al, 2001). In this case, as elsewhere, nurse prescribing is a double-edged sword, but it seem from this research that the nurses felt that the benefits outweighed their concerns, and their concerns were, after all, possible to overcome through additional training. Direct versus indirect consequences. Some of the indirect consequences may be easier to appreciate than the direct consequences, while some of the direct consequences may be less popular, in a sense, because they benefit members of the institutional system in ways less acceptable to some of the professionally defined or client-defined groups within the system. For example, if the direct consequence of nurse prescribing is a reduction in doctors’ workloads, this will benefit doctors, and may indirectly benefit patients by providing more or better quality doctor-patient contact, and patient outcomes. But there is no evidence so suggest that this rather optimistic viewpoint could be true. A reduction in doctors’ workloads may demonstrate no improvement in patient care, but an increase in nurses’ workloads could be viewed as having more potential indirect consequences for the patient experience. Deontological debates also raise this issue, and the question is where does the duty of the nurse truly lie? Another indirect consequence of the innovation might be the burden placed on nurses to conform to this professional development and to adhere to the directive. Nurses who do not wish this level of responsibility and autonomy may suffer personally and professionally, finding themselves non-conformists through no fault of their own. However, if another consequence is an enhancement in the status (and pay) of nurses, nurses who prefer not to prescribe could be viewed as holding the profession back. Anticipated versus unanticipated consequences. It is difficult to evaluate the anticipated consequences against the unanticipated ones, given that there is little literature discussing these. Some anticipated consequences might relate to improvements in medication education by nurses (Rycroft-Malone et al, 2000), whereby the nurses will be more knowledgeable, competent and perhaps confident in this activity. This is an important issue in the modern healthcare service where consumerism has become one of the most powerful driving and defining forces (Rycroft-Malone et al, 2001). It is this kind of consumer power which contributes to future policy direction, after all, although the current rhetoric, with its implicit assumption that greater consumer involvement in health care is both desirable and beneficial (Rycroft-Malone, 2001), could be challenged by those who believe that the conferred authority of medicine (and nursing) should take the lead. This author can only project certain consequences, some of which may relate to consume r power and the negotiation of power dynamics between different groups. However, it is debateable if these could be considered anticipated or foreseeable consequences. Another anticipated consequence of this innovation is the close evaluation of the innovation, with inevitable close scrutiny of the nursing profession and its actions in response to the new powers and responsibilities. Latter and Courtenay (2004) in a review of evaluations of nurse prescribing found that the initiative had been largely successful. However, they also identify areas for much further scrutiny and consideration, such as gaps in the knowledge base about prescribing, the nature of the evidence about nurse prescribing, and the need to evaluate the extension of prescribing powers to nurses working outside the initially defined settings (Latter and Courtenay, 2004). It would appear that the nurse-patient relationship may be a positive dimension of patients’ perceptions of nurse prescribing, but there is a need to further evaluate the more intermittent contacts that patients may experience with nurses in certain settings (Latter and Courtenay, 2004). McKenna and Keeney (2004) found that there is still a lack of understanding of the roles of, in particular, community and specialist nurses, but that there is public support for nurse prescribing. Questions still remain about nurses’ ability to be effective in working outside their standard professional area (McKenna and Keeney, 2004). This raises questions about the consequences for nurses in how they interact with their clients, and suggests that nurse prescribing may contribute to changing the professional ‘face’ of nursing. Conclusion The modernisation of the NHS, with its emphasis on timely and effective delivery of services, has been a key factor in the implementation of nurse prescribing and its development into independent prescribing, even into the hospital setting (Clegg et al, 2006). The history of nurse prescribing demonstrates the drive for professional growth in certain areas, sanctioned by changes in the context of service delivery, but hampered by traditional roles and concepts of professional domain. Debates also consider the challenges of training, legal issues, professional issues, budgetary and practical issues surrounding nurse prescribing (Clegg et al, 2004). What is most apparent from this examination of the literature, however, is that while the embryonic stage of nurse prescribing is long gone, the innovation is still undergoing a process of growth and maturation, which is persistently emergent and therefore leaving the status of the profession in relation to this issue largely unformed. This examination of nurse prescribing has shown that change spreads by a process of diffusion, which could be viewed in retrospect as a piecemeal process driven from different directions and according to the perhaps hidden agendas of different agencies, such as nurses, the government, and the consumer. More research is required to examine the ongoing growth and consequences of this innovation, for the professions and the clients, now that it has become an established part of healthcare practice in the UK. 2,500 Words References Bates, C. (2002) Independent nurse prescribing. RCM Midwives Journal 5 (2) 63. Berry, D., Courtenay, M. and Versellini, E. (2006) Attitudes towards, and information needs in relation to, supplementary nurse prescribing in the UK: an empirical study. Journal of Clinical Nursing. 15 22-28. Crown, J. (2003) Bringing practice up to date: progress with nurse prescribing. Nurse Prescribing 1 (2) 56-58. Gooch, S. and Bennett, G. (1999) Extending prescribing: nurse prescribing and the Crown Review. Hospital Medicine 60 (10) 718-721. Jones, M. (2004) Case Report. Nurse prescribing: a case study in policy influence. Journal of Nursing Management 12 266-272. King, R.L. (2004) Nurses’ perceptions of their pharmacology educational needs. Journal of Advanced Nursing 45 (4) 392-400. Laresen, D. (2004) Issues affecting the growth of independent prescribing. Nursing Standard 22 (19) 33-39. Latter, S. and Courtenay, M. (2004) Effectiveness of nurse prescribing: a review of the literature. Journal of Clinical Nursing 13 26-32. McCartney, W., Tyrer, S., Bracier, M. and Prayle, D. (1999) Nurse prescribing: radicalism or tokenism? Journal of Advanced Nursing 29 (2) 348-354. McKenna, H. and Keeney, S. (2004) Community nursing: health professional and public perceptions. Journal of Advanced Nursing 48 (1) 17-25. NHS Scotland (2002) Extending Independent Nurse Prescribing within NHS Scotland http://www.scotland.gov.uk/Publications/2002/09/15042/8426. Nolan, P., Hage, S., Badger, F. et al (2001) Mental health nurses’ perceptions of nurse prescribing. Journal of Advanced Nursing 36 (4) 527-534. Rogers, E. M. New Product Adoption and Diffusion. Journal of Consumer Research. Volume 2 March 1976 pp. 290 -301. Rogers, E. M. (1962). Diffusion of Innovations. The Free Press. New York. Rycroft-Malone, J., Latter, S., Yerrell, P. and Shaw, D. (2001) Consumerism in health care: thecase of medication education. Journal of Nursing Management. 9 2221-230. Rycroft-Malone, J., Latter, S., Yerrell, P. and Shaw, D. (2000) Nursing and medication education. Nursing Standard 35-39. Stephenson, T. (2000) Implications of the Crown Report and nurse prescribing. Archives of Disease in Childhood. 83 (3) 199-202.

Function of E-Book Essay

Books are no doubt the main element in teaching and learning activities. As we all know printed books have already been used for a very long time. However in this modern era, books in electronic forms (eBooks) are taking place. EBooks had already been introduced not only for adults but children too. Finally, eBooks are already evolving slowly to take place in teaching and learning. A powerful stimulus for the production of a range of electronic instrument for education has been provided by the latest technology inventions. Numerous ideas and educational materials are invented and extensively published electronically to support the field of teaching and learning, however it is still unclear how far all of this is of use among the students and teachers when it comes to the virtual teaching and learning. Suggestions on how to improve the quality of the products and materials that are already available are still in great demand as the existing electronic books have not completely replaced the physical counterpart. The gap between utilitarian and usefulness is quite wide to prove the lack of effectiveness of the first generation of e-books, and the progress of e-books has been led majorly by technology instead of the user’s demand. In the education field, E-books can be found in various type of media instrument like CD-Rom, the internet and in any portable reading materials. Variety types of element are implemented in e-books, for example fiction and non-fiction. A textbook is a source of information on a particular subject. An electronic textbook on the other hand is almost the same but it is more special as e-textbook is an e-book that has a content of educational material for teaching and learning process. E-textbooks are now officially known as educational source that have already published electronically to help in both teaching and learning methods. They are ready to be used within a computer environment, through media such as internet or CD-ROM. In the early 1990s, the spread of educational multimedia was surprisingly very fast and it was proven by the people that it is more beneficial when converting printed publication into electronic form. Apart from that, it has been discussed that e-book is basically implemented to improve the process of studying outside the classroom, and as time goes by, a technological instrument was made where a powerful incentive is created to invent such electronic material for the students. It is better for the people to be updated to any information to learn by using e-book as printed books are always out-of-date and are only replaced with an average of eight years. Limitless and faster access to any latest news and information can be experienced via electronic learning (Hamilton et al., 2001). It was said that electronic education will benefit a lot of people because of its capability to enhance the co-operation and among the students and the teachers (Hambrecht, 2000). Apart from that, higher success rate can be seen. However more effort should be contributed towards promoting e-book among the new generations as financial support plays an important role in this matte (Wilson, 2003). Similar to the ordinary printed books, e-book helps the readers to understand and focus on important messages by underlining them and writing simple notes. In addition, e-books are user-friendly too as it is installed with portable dictionary program which made it easier to look up for unfamiliar words. E-book has definitely made the teaching and learning process to be more interesting than ever because the user get to watch clips and interact with a variety of specialities. It has been proven that the youngsters can gain a lot from the added applications (Maynard and McKnight, 2001). At schools, e-textbooks on the other hand will reduce the number of printed textbooks that not only burden both the teachers and students carrying them to-and-fro around the school compound. This enables the teacher to easily bring the notes including the exercises to be given to the student which thus increases the effectiveness of teaching. With the presence if the electronic book, space can be saved which particularly helps a lot in places mainly the libraries. Decades ago, e-books were not preferred because the prices were too high. In the year 2000, the production of e-books have became larger and the cost of each e-book is lowered (Mayfield, 2000). This indicates that a major procedure in promoting the usage of e-textbooks in school had been done. Another form of e-book, CD-ROM also known as the copy of the encyclopedia is also famous among the students nowadays. They can easily get copies of the syllabus of their subjects in order for them to study back at home and easily bring the topics for discussion among their peers. Another branch of e-book, Hypertextbooks is a famous instrument of interactive studying on the internet in the western country. This electronic file containing the learning materials enables the user to study at their own rhythm and the students will send their assignment to the respective person through email. This concludes that with the upgrading of the process of studying, the students will no longer have the reason not to send their assignments on time. Top of the information, at schools teachers will have no problem to control the class because the students will be more focused and enthusiastic to carry on with their assignments compared to the printed pages. Even though e-textbooks can contribute towards the improvement in assisting the process of teaching and learning, there are still factors that resist their acceptance such as the insufficient number of computers and labs and the low number of publishers. This signifies that e-book can help in the education field but the chance to make it a reality might prove problematic. According to Hambrecht’s theory, it is believed that e-education is potential in bringing the students and teachers to come together as one in order to enhance the class session’s activities (Hambrecht, 2000). The research about CD-ROM clarified that users will be more interested to learn and use their resources. The children especially, find that learning is more fun with the presence of beautiful graphics and sound effects. This thus motivates them to continue to learn more which in return will boost their thinking skills. Teachers on the other hand love this way of teaching as it is both entertaining and educational. The e-book users prefer to use this modern way of learning because of the more presentable format which brings a brand new perspective towards the people to experience a more lively way of reading especially the story book lovers. Children once exposed to the usage of e-book they will be used to electronic devices and in future, they will no longer rely on the old traditional method which is the printed book. Electronic texts are no doubt a passage for the generation to get an easy access in education for further study and analysis. The fertile ground for the improvement of teaching and learning, e-book, can benefit the generations greatly in terms of the enjoyment of interesting studying method. As a conclusion, the educators should look into this matter more clearly and make an effort to add electronic texts in their teachings if they haven’t start doing so. Cooperation among the parents and the educators are the key to success to make a change to the younger generations. This foundation will for sure end the upcoming obstacle in generating intellectual students. Reference Hambrecht, W. (2000), Exploring a New Frontier, Corporate E-Learning. Hamilton, R. , Richards, C. and Sharp, C. (2001), â€Å"An examination of e-learning and e-books†, available at: www. dcs. napier. ac. uk/ , mm/socbytes/jun2001/Jun2001_9. htm (accessed 20 November 2010) Mayfield, K. (2000), â€Å" Read a g ood e-textbook lately? †, Wired News, available at: www. wired. com/news/culture/0,1284,38059,00. html (accessed 12 November 2010). Maynard, S. and McKnight, C. (2001a), â€Å"Children’s comprehension of electronic books: an empirical study†, The New Review of Children’s Literature and Librarianship, Vol. 7, pp. 29-53. Maynard, S. and McKnight, C. (2001b), â€Å"Electronic books for children in UK public libraries†, The Electronic Library, Vol. 19 No. 6, pp. 405-23. Sally Maynard, Emily Cheyne, (2005) â€Å"Can electronic textbooks help children to learn? â€Å", Electronic Library, The, Vol. 23 Iss: 1, pp. 103 – 115. November,25, 2010 http://www. emeraldinsight. com/journals. htm? articleid=1464898 Wilson, R. (2003), â€Å"E-education in the UK†, Journal of Digital Information, Vol. 3 No. 4.

Chapter 5 Case Study Stop! Wait! I am pulling down a menu! Essay

Management Information Systems In San Jose, California has the smallest officer-to-resident ratio that is one police officer for 925 residents (Oz, 2009, P. 190). However this city is considered one of the safest larger cities in the US (Oz, 2009, P. 190). This implied that the city offices were efficient and productive and were using the right and better technology and software tools to manage city police, fire communications and dispatching functions. â€Å"The Computer Aided Dispatch (CAD) system is a highly specialized application that is designed to facilitate coordinated communication, assignment and tracking of Police and Fire Department resources in response to calls-for service.† (Michael, A. Smith .2004-2005, Santa Clara County Civil Grand jury report) In 2004 City replaced all text based CAD system with new Windows based touch screen system by spending $4.7 million (Oz, 2009, P. 190). However the new CAD system was plagued with problems such as non-user friendly user interface, software bugs, user issues of adapting to new technology, inadequacy of user training, increased difficulty in issuing the Code 99 commands, patrol officers needing longer time to find out whether a person they have stopped has a violent criminal and system crash just two days after the system went live. According to the case study and the Santa Clara County Civil Grand jury report none of the above issue (that cause the failure of the new CAD system) were due to hardware but majority of them were directly related to the application software and the design of the system. (E.g. code 99 command issue, system crash, non-user friendly interface etc.) The other major issue was relating to the lack of user involvement during software design, implementation and inadequacy of user training. That is why Santa Clara County Civil Grand Jury recommended that in future IT project developments City of San Jose management should mandate that representatives from all levels affected by the IT project be included in every stage of specification, development and deployment. (Michael, A. Smith .2004-2005,  Santa Clara County Civil Grand jury report) References; Oz, E. (2009). Management Information Systems. Boston, MA: Course Technology Cengage Learning Michael, A. Smith (2004-2005) Santa Clara County Civil Grand jury report, retrieved from: http://www.911dispatch.com/info/cad/rfp/sj_cad_invest.pdf