Nurse-led care in dermatology: a review of the literature

Dermatology nurse prescribing in China: a Delphi method

Objectives: To identify the dermatological system drugs that may be prescribed by Chinese dermatological nurses through expert consensus.

Methods: A 2-round study, consisting of 32 medical and nursing experts, was conducted using the Delphi method from September 2019 to June 2020. Microsoft Excel 2019 and IBM SPSS Ver. 22 were used to analyze the results of the consultations.

Results: A total of 63 drugs across 13 categories were identified as relevant to Chinese nurses working in dermatological departments. Among these drugs, 1 drug was generally prescribed independently, 17 drugs tended to be prescribed collaboratively, and 45 were prescribed either independently or in collaboration with others.

Conclusions: This expert consensus determines the prescription drugs that may be prescribed by dermatology nurses in China, which can be used as the key content of prescription drug training for dermatology nurses in future. The results of the study could provide a basis for the implementation of nurses’ prescription rights in China in future and provide a reference for the formulation of relevant legislation on nurses’ prescription rights.

Patients' perspectives on quality of care for chronic hand eczema: a qualitative study

Background

Hand eczema (HE) has a significant impact on patients’ quality of life and work‐related activities. However, little is known about the patients' perspectives on quality of care for HE.

Objectives

To evaluate the patient perspective of the HE care process in a tertiary referral center.

Methods

Qualitative, semi‐structured focus groups were carried out, recorded, transcribed, and analysed using an inductive‐deductive thematic approach.

Results

Fifteen patients participated in four focus groups. Time and attention, together with being listened to and understood by the health care professional, were the most important aspects of care for HE mentioned by participants. Other aspects of care that were regarded as important were that diagnoses, causes and follow‐up of HE were not always clear to the participant; more psychosocial support was needed, and that participants experienced frequent changes in doctors. Information provided by nurses was valuable, but more individualized advice was needed.

Conclusions

To better meet the needs of patients, more explanation should be given about the causes of HE and the final diagnosis. Besides focusing on the treatment, it is also important to focus on its impact on the patient and options for psychosocial and peer support should be discussed. Furthermore, the beneficial role of the specialized nurse as part of integrated care was emphasized.

Assessing the compliance of systematic review articles published in leading dermatology journals with the PRISMA statement guidelines: A systematic review

Background

Reporting quality of systematic reviews and meta-analyses is of critical importance in dermatology because of their key role in informing health care decisions.

Objective

To assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines.

Methods

This review was carried out in accordance with PRISMA guidelines. Included studies were reviews published across 6 years in the top 4 highest-impact-factor dermatology journals of 2017. Records and full texts were screened independently. Data analysis was conducted with univariate multivariable linear regression. The primary outcome was to assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the PRISMA statement.

Results

A total of 166 studies were included and mean PRISMA compliance across all articles was 73%. Compliance significantly improved over time (β = .016; P = <.001). The worst reported checklist item was item 5 (reporting on protocol existence), with a compliance of 15% of articles.

Conclusion

PRISMA compliance within leading dermatology journals could be improved; however, it is steadily improving.

The role of the nurse in the care and management of patients with atopic dermatitis

BACKGROUND

The purpose of this paper is to provide an overview of key aspects of specialised dermatology nursing practice in the management of patients with moderate to severe atopic dermatitis. The role of dermatology nurse specialists in supporting patients and promoting disease understanding, education and treatment adherence continues to evolve. As features of specialised nursing care can also inform other nursing staff in a wide range of care settings, an overview of key components is examined. Observations presented are from a pan-European perspective and represent the collected view of a group of dermatology nurse specialists, dermatologists and patient advocates following two round-table discussions.

MAIN BODY

Atopic dermatitis is a common, chronic, inflammatory disease characterised by erythematous/scaling skin lesions, with often intense pruritus. Disease course is cyclic with periodic disease flares of varying intensity, presenting management challenges to patients and families. Dermatology nurse specialists play a key role in providing education and substantial patient support to improve treatment outcomes and quality of life to patients and their family, delivered within a multidisciplinary team framework. Nurse-led education and 'eczema schools' are of benefit in reducing disease severity and improving quality of life by enhancing self-management, adherence and patient engagement. eHealth tools, such as patient portals or online training platforms, can provide online learning, individualised education, and help to improve engagement. These and other initiatives, such as written action plans, are all essential to improve or maintain treatment adherence, self-management and quality of life.

CONCLUSIONS

Dermatology nurse specialists play a central role in the assessment and management of moderate to severe atopic dermatitis patients and families. This places them in an ideal position to build strong and often long-term relationships with patients and parents. Such engagement promotes trust, assists in setting realistic expectations of treatment and outcomes, and enhances self-management and engagement in their own care. Providing emotional support, as well as formal and systematic education (including individualised practical advice) all contribute to improved treatment adherence and can enhance the quality of life of patients and their families throughout the course of this long-term condition.

Reorganising dermatology care: predictors of the substitution of secondary care with primary care

Background

The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision.

Methods

This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors.

Results

A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+.

Conclusion

The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

Improving psoriasis patients' adherence to topical drugs: a systematic review

Background: Poor adherence to topical antipsoriatic drugs limits treatment effectiveness.Objective: The aim of this study was to investigate how health care providers may improve psoriasis patients' adherence to topical treatment.Materials and methods: A systematic literature search was performed for English-language articles in Embase, Medline, PsycINFO, Cinahl, Scopus, and the Cochrane Library.Results: Ten studies of varying quality were identified. Two randomized controlled trials (RCTs) testing the adherence-improving potential of interventions by health care providers to support patients showed improvement in adherence to topical treatment. In a prospective study with a pre/postdesign, an individualized, face-to-face consultation reported an improvement in patient-reported adherence to topical treatment over a 9-week period. Based on seven qualitative studies obtaining insights from either patients or health care providers, health care providers may need to address socio-economic factors, health care system factors, and treatment-, patient-, and disease-related factors in interventions that aim to improve the adherence of psoriasis patients to topical antipsoriatic drugs.Conclusion: There is a need to develop better adherence-improving interventions. A good patient-health care provider relationship is considered crucial to adherence and may be an important intervention target. Before interventions to improve adherence to topicals can be recommended for the clinic, the intervention should be tested in high-quality RCTs.

Organisational impact of the V150 nurse prescribing qualification

An initial literature search identified a deficit in the non-medical prescribing evidence base in relation to V150 community practitioner nurse prescribing. Nineteen V150 prescribers from eight professional roles, and prescribing for a variety of conditions, along with three NMP leads, participated in this evaluation. The evaluation used a mixed methodology of questionnaires and telephone interviews; 19 V150 prescribers participated, with all of them completing the online questionnaire. Two of these also consented to a follow-up telephone interview. Three NMP leads completed the online questionnaire. The findings suggested a benefit to the wider health organisation with regard to reduced attendance at walk-in centres, GP practices and the emergency department. It is anticipated that the findings from this study may be prove useful to NMP leads, NMP groups and commissioners, as well as V150 prescribers.

The Spanish Psoriasis Patients' Association According to Its Members: Cross-Sectional Descriptive Study of Members' Opinions of the Association's Functions

INTRODUCTION

Patient associations form part of health care systems, but little is known about how their members' view the functionality of these associations and whether they endorse their goals and activities.

OBJECTIVE

To study how the members of the leading Spanish association of patients with psoriasis and their relatives view the group's functioning.

MATERIAL AND METHODS

Survey study using a self-administered questionnaire answered by members of the association (total membership, 26 349 persons). The credibility of the association and respondents' confidence in and satisfaction with it were studied and compared with their attitudes toward other agents in the health care system. A Rasch model was used to analyze respondents' ranking of functions. Analysis of variance was used to study between-group differences.

RESULTS

A total of 746 members participated (response rate 2.83%). The association's credibility was rated in second place, after that of specialists who treat psoriasis. Support for the association functions was good (7.53 on a scale of 0 to 10). The function the members rated highest was the raising of societal awareness of psoriasis and its problems. Rated lowest were functions related to personal services for members. Educational level was the only participant factor associated with significant differences in evaluations (P<.05).

CONCLUSIONS

The psoriasis association contributes by disseminating information about the disease and patient care, and it serves to represent patients. Health professionals and institutions should take the association into account in their efforts to deal with the disease and in designing effective policies.

Professional caregivers' knowledge in dermatology : Improving knowledge and communication to dermatologists in geriatric facilities

BACKGROUND

Research regarding effective collaboration and communication between professional caregivers and dermatologists and the need for further education and training for caregivers in the field of geriatric dermatology still remains relatively scarce.

OBJECTIVE

To document the state of knowledge of professional caregivers in the field of geriatric dermatology and make recommendations for dermatological education and postgraduate training.

METHODS

A questionnaire with open and closed questions was used to evaluate the level of knowledge and current need for information in geriatric dermatology. A total of 58 professional caregivers from several hospital departments, including geriatric wards and nursing homes participated in this study. Quantitative and qualitative data were generated and responses to open questions were categorized according to the most quoted contents. The study was approved by the Charité University in Berlin ethics committee.

RESULTS

The study demonstrates that there is a lack of dermatological knowledge. Participants indicated a huge information need regarding skin tumors (77.2 %), prevention of skin diseases (50.0 %) and pruritus (41.4 %). According to the caregivers, communication problems with physicians arise in view of using standardized terms of skin diseases (22.9 %) and formulating unclear care records of skin diseases (20.8 %).

CONCLUSION

Difficulties in communication between professional caregivers and physicians can influence patients' punctual and well-founded treatment; therefore, further education must be mediated vividly and practically. Moreover, training should focus on learning standardized terms and descriptions for optimizing the flow of information with physicians and written communication, such as care records.

Outpatient services and primary care: scoping review, substudies and international comparisons

Aim

This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.

Findings from the scoping review

Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.

Findings from the substudies

Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.

Conclusions

For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.

Funding

The NIHR Health Services and Delivery Research programme.

Providing Guidance for Patients With Moderate-to-Severe Psoriasis Who Are Candidates for Biologic Therapy

Psoriasis is a chronic, immune-mediated disease characterized by itchy, scaly, and often painful plaques in the skin. Psoriasis can have significant psychosocial burdens and increased risks for numerous comorbidities, including diabetes, hypertension, and cardiovascular disease, particularly in patients with moderate-to-severe disease. Dermatology nurse practitioners and physician assistants are an important part of the healthcare team, contributing to all aspects of psoriasis management. This review reinforces the unique aspects of care that nurse practitioners and physician assistants provide to patients with psoriasis, such as facilitating conversations about managing disease, setting appropriate expectations, and considering treatment options, including when treatment response or tolerability is suboptimal. The importance of relationship building is stressed. Patient management topics discussed include helpful tips about assessing treatment options, initiating biologic therapy, optimizing patient adherence, and managing comorbidities. Also reviewed are how to deal with common barriers including lack of knowledge about psoriasis or making healthy lifestyle changes, fear of injections or side effect risks, lack of health insurance, and concerns about treatment costs. Overall, by forming meaningful relationships and engaging patients in their psoriasis care, nurse practitioners and physician assistants can help to optimize clinical efficacy outcomes and consistently manage moderate-to-severe psoriasis and its comorbidities over the patient’s life course.

E-health in caring for patients with atopic dermatitis: a randomized controlled cost-effectiveness study of internet-guided monitoring and online self-management training

BACKGROUND

The Dermatology Department of the University Medical Centre Utrecht, the Netherlands, developed an e-health portal for patients with atopic dermatitis (AD), consisting of e-consultation, a patient-tailored website, monitoring and self-management training.

OBJECTIVES

To determine the cost-effectiveness of individualized e-health compared with usual face-to-face care for children and adults with AD.

METHODS

A randomized controlled cost-effectiveness study from a societal perspective in adults and parents of children with moderate AD. Outcomes were quality of life, severity of AD, itching and direct and indirect costs. Data were collected at baseline and at 3 and 12 months after randomization. Linear mixed models were used to analyse clinical outcomes. After multiple imputation of missing data, costs and differences in costs were calculated over a period of 1 year.

RESULTS

In total, 199 patients were included. There were no significant differences in disease-specific quality of life, severity of AD and intensity of itching between both groups at the three time points. The difference in direct costs between the intervention and control groups was €24 [95% confidence interval (CI) -360 to 383], whereas this difference was -€618 (95% CI -2502 to 1143) for indirect costs. Overall, individual e-health was expected to save €594 (95% CI -2545 to 1227) per patient in the first year of treatment, mainly through a reduction in work absenteeism. Uncertainty analyses revealed that the probability of e-health reducing costs was estimated to be ≥ 73%.

CONCLUSIONS

E-health during follow-up of patients with AD is, after initial diagnosis and treatment during face-to-face contact, just as effective as usual face-to-face care with regard to quality of life and severity of disease. However, when costs are considered, e-health is likely to result in substantial cost savings. Therefore, e-health is a valuable service for patients with AD.

Meeting the physical health-care needs of people with substance misuse problems: evaluation of a nurse-led blood-borne virus programme

People who inject substances are at high risk of many physical health problems. The Blood-Borne Virus Programme (BBVP) is a nurse-led health screening programme for blood-borne conditions in substance misusers. The aim of this study was to evaluate the service delivery, organization, and outcomes of the BBVP. The researchers used a case study with three units of analysis: BBVP clinical activities during 1 year using a prospective audit; service users' (n = 20) and professional stakeholders' (n = 10) experiences of the BBVP using semistructured interviews; and service users' (n = 132) satisfaction with the BBVP using a satisfaction measure. The BBVP conducted 4450 consultations with 1940 service users; 847 of whom were new, and presented with many health problems compromising their physical health. The BBVP provided a range of interventions meeting its users' physical health needs. Users and other stakeholders were very satisfied with the service, and suggested ways in which the service might improve. The BBVP appeared to meet the physical health-care needs of people dependent on drugs. Nurse-led services, such as the BBVP, offer a solution that, in the view of users and professional stakeholders, is impacting significantly on the physical health and well-being of people dependent on drugs.

Skin care in the older person: a focus on the use of emollients

This article gives an overview of pathophysiological changes in the older person's skin, with particular focus on dry skin and the important use of emollient therapy. This includes guidance on emollient choice, function and application. Education is emphasized as an important factor in patient/carer concordance, with additional advice also recommended to extend education to other health care professionals in terms of correct usage and prescription amounts. Best practice of the use of emollient therapy is the main objective of this article, promoting the health professional to place skin care assessment high on the patient need agenda, and to recognize this therapy as the first-line treatment in all dry skin management.

A Review of Effective Methods of Delivery of Care: Skill-Mix and Service Transfer to Primary Care Settings

Aims

Health policy in England is seeking to minimise hospital use and provide access to services in a primary healthcare setting and maximise skill-mix, driven by issues such as cost and access. The aim of this review was to determine the effectiveness of increased use of skill-mix and service transfer within general and oral healthcare. Secondary outcome measures were related to cost, quality, access, health outcomes and satisfaction.

Methods

Data sources were the Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination DARE, British Nursing Index, CINAHL, EMBASE, MEDLINE, and PsycINFO from 1996 to August 2008. The reference lists of relevant papers were scanned to identify additional studies.

Data selection

A rapid appraisal of systematic reviews, randomised controlled trials, controlled trials and service evaluations in relation to specialist services, practitioners with a special interest, medical and dental, nursing and dental care professionals, together with evidence of service shifts from secondary to primary care was undertaken.

Results

A total of 206 papers were reviewed. All titles and abstracts of articles and papers found were extracted and validated according to predefined criteria. They were screened for relevance by two researchers, who assessed trial quality and extracted data. Twenty-six papers met the inclusion criteria. The literature demonstrated limited evidence of the cost-effectiveness and health outcomes associated with changes in setting and skill-mix. However, there was evidence of improved access, patient and professional satisfaction.

Conclusions

There is an overwhelming need for well-designed interventions with robust evaluation to examine cost-effectiveness and benefits to patients and the health workforce.

The Digital Eczema Centre Utrecht

The University Medical Centre Utrecht (UMC Utrecht) has developed an eczema portal that combines e-consulting, monitoring and self-management training by a dermatology nurse online for patients and parents of young children with atopic dermatitis (AD). Patient satisfaction with the portal was high. It could be extended to become a Digital Eczema Centre for multidisciplinary collaboration between health-care providers from different locations and the patient. Before starting the construction of the Digital Eczema Centre, the feasibility was examined by carrying out a business case analysis. The purposes, strength and weaknesses showed that the Digital Eczema Centre offered opportunities to improve care for patients with AD. The financial analysis resulted in a medium/best case scenario with a positive result of €50–240,000 over a period of five years. We expect that the Digital Eczema Centre will increase the accessibility and quality of care. The web-based patient record and the digital chain-of-care promote the involvement of patients, parents and multidisciplinary teams as well as the continuity and coordination of care.

Integrated, multidisciplinary care for hand eczema: design of a randomized controlled trial and cost-effectiveness study

Background

The individual and societal burden of hand eczema is high. Literature indicates that moderate to severe hand eczema is a disease with a poor prognosis. Many patients are hampered in their daily activities, including work. High costs are related to high medical consumption, productivity loss and sick leave. Usual care is suboptimal, due to a lack of optimal instruction and coordination of care, and communication with the general practitioner/occupational physician and people involved at the workplace. Therefore, an integrated, multidisciplinary intervention involving a dermatologist, a care manager, a specialized nurse and a clinical occupational physician was developed. This paper describes the design of a study to investigate the effectiveness and cost-effectiveness of integrated care for hand eczema by a multidisciplinary team, coordinated by a care manager, consisting of instruction on avoiding relevant contact factors, both in the occupational and in the private environment, optimal skin care and treatment, compared to usual, dermatologist-led care.

Methods

The study is a multicentre, randomized, controlled trial with an economic evaluation alongside. The study population consists of patients with chronic, moderate to severe hand eczema, who visit an outpatient clinic of one of the participating 5 (three university and two general) hospitals. Integrated, multidisciplinary care, coordinated by a care manager, including allergo-dermatological evaluation by a dermatologist, occupational intervention by a clinical occupational physician, and counselling by a specialized nurse on optimizing topical treatment and skin care will be compared with usual care by a dermatologist. The primary outcome measure is the cumulative difference in reduction of the clinical severity score HECSI between the groups. Secondary outcome measures are the patient's global assessment, specific quality of life with regard to the hands, generic quality of life, sick leave and patient satisfaction. An economic evaluation will be conducted alongside the RCT. Direct and indirect costs will be measured. Outcome measures will be assessed at baseline and after 4, 12, 26 and 52 weeks. All statistical analyses will be performed on the intention-to-treat principle. In addition, per protocol analyses will be carried out.

Discussion

To improve societal participation of patients with moderate to severe hand eczema, an integrated care intervention was developed involving both person-related and environmental factors. Such integrated care is expected to improve the patients' clinical signs, quality of life and to reduce sick leave and medical costs. Results will become available in 2011.

The many faces of depression in primary care

Depression is a serious global health problem. It creates a huge economic burden on society and on families and has serious and pervasive health impacts on the individual and their families. Specialized psychiatric services are often scarce and thus the bulk of care delivery for depression has fallen to primary care providers, including advanced practice nurses and experienced nurses who work in under-serviced regions. These health professionals require advanced knowledge about the many faces that depression can display. This article reviews some of the faces of depression seen by primary care providers in their practices. Considering depression as a heterogeneous spectrum disorder requires attention to both the details of the clinical presentation, as well as contextual factors. Recommendations around engagement and potential interventions will also be discussed, in terms of the client population as well as for the practitioner who may be isolated by geography or discipline.

The impact and effectiveness of nurse-led care in the management of acute and chronic pain: a review of the literature

AIMS AND OBJECTIVES

To identify, summarise and critically appraise the current evidence regarding the impact and effectiveness of nurse-led care in acute and chronic pain.

BACKGROUND

A diverse range of models of care exist within the services available for the management of acute and chronic pain. Primary studies have been conducted evaluating these models, but, review and synthesis of the findings from these studies has not been undertaken.

DESIGN

Literature review.

METHOD

Searches of Pubmed (NLM) Medline, CINAHL, Web of Knowledge (Science Index, Social Science index), British Nursing Index from January 1996-March 2007 were conducted. The searches were supplemented by an extensive hand search of the literature through references identified from retrieved articles and by contact with experts in the field.

RESULTS

Twenty-one relevant publications were identified and included findings from both primary and secondary care. The areas, in which nurses, caring for patients in pain are involved, include assessment, monitoring, evaluation of pain, interdisciplinary collaboration and medicines management. Education programmes delivered by specialist nurses can improve the assessment and documentation of acute and chronic pain. Educational interventions and the use of protocols by specialist nurses can improve patients understanding of their condition and improve pain control. Acute pain teams, led by nurses, can reduce pain intensity and are cost effective.

CONCLUSIONS

Nurses play key roles in the diverse range of models of care that exist in acute and chronic pain. However, there are methodological weaknesses across this body of research evidence and under researched issues that point to a need for further rigorous evaluation.

RELEVANCE TO CLINICAL PRACTICE

Nurse-led care is an integral element of the pain services offered to patients. This review highlights the effect of this care and the issues that require consideration by those responsible for the development of nurse-led models in acute and chronic pain.

Nurse supplementary prescribing for patients with diabetes: a national questionnaire survey

AIMS AND OBJECTIVES

To examine the prescribing practices of nurse supplementary prescribing in diabetes.

BACKGROUND

Nurses in several roles are involved in the management of medicines for patients with diabetes. Nurse prescribing should help optimise these roles. Nurses in the UK have virtually the same independent prescribing rights as doctors. There is little or no evidence on the extent to which nurse supplementary prescribing is used, or the impact and activity of nurse supplementary prescribing for patients with diabetes.

DESIGN

Survey.

METHOD

A random sample of 214 nurse supplementary prescribers self-completed a written questionnaire.

RESULTS

The majority of nurses held an academic qualification at degree level or higher, had a wealth of clinical experience, worked full-time, were based in primary care and worked in general practice. The majority of nurses prescribed between one and five items a week. Oral anti-diabetic drugs, hypertension and lipid-regulating drugs and insulins were the products most often prescribed. Over 85% had undertaken specialist training in diabetes prior to undertaking the prescribing programme.

CONCLUSION

Supplementary prescribing provides a practical and useful framework within which to prescribe medicines for patients with diabetes and its associated complications. Specialist diabetes training is a necessary prerequisite for nurses prescribing in this area. It is evident that there is still a place for supplementary prescribing.

IMPLICATIONS FOR CLINICAL PRACTICE

* Recent legislative changes mean that nurses can now independently prescribe practically any drug. * Nurses in general practice appear to prescribe most frequently as a nurse supplementary prescriber for patients with diabetes. * Nurse supplementary prescribers are likely to use this mode of prescribing to deliver medicines to patients with diabetes. * Over two-thirds prescribe for common but serious complications of diabetes, e.g. hypertension, hyperlipidaemia and cardiovascular disease.

The role of inter-professional relationships and support for nurse prescribing in acute and chronic pain

AIM

This paper is a report of a study to explore nurse prescribers' views on the role of inter-professional relationships and other means of support for nurse prescribing for patients in acute and chronic pain.

BACKGROUND

Research indicates that good team relationships are important for supporting nurse prescribing but that poor understanding of the role by other healthcare professionals can act as a barrier. While collaborative working is central to the role of pain nurses, there is a lack of research on the impact of nurse prescribing on inter-professional working or the support needs of these nurses.

METHOD

A qualitative approach was adopted using thematic analysis of semi-structured interview data collected during 2006 and 2007. Participants were 26 nurses who prescribed medicines for patients with acute and/or chronic pain.

FINDINGS

Nurses' believed that prescribing encouraged collaborative working and sharing of knowledge across professional boundaries and that this helped to broaden understanding of the wider remit of pain management. Collaboration with doctors served a number of functions, including support and continuous learning. Barriers to effective nurse prescribing were a lack of understanding of its role amongst healthcare professionals and inadequate support. Formal support structures, such as regular clinical supervision, were seen as crucial to meeting nurses' ongoing learning.

CONCLUSION

Factors that promote understanding of nurse prescribing and support inter-professional relationships are likely to have a positive impact on the effectiveness of nurse prescribing. A more consistent approach is required within organisations to support nurse prescribing.

The use of cognitive continuum theory and patient scenarios to explore nurse prescribers’ pharmacological knowledge and decision-making

BACKGROUND

Nurses have been involved in prescribing in England since 1996, and to date over 41,000 nurses are registered with the Nursing and Midwifery Council as prescribers. The majority of evaluative research on nurse prescribing is descriptive and relies on self-report and assessment of patient satisfaction.

OBJECTIVES

To explore and test nurse prescribers' pharmacological knowledge and decision-making.

DESIGN

An exploratory approach to test the usefulness of patient scenarios in addressing the reasons why nurses decide whether or not to prescribe was utilised. Semi-structured interviews with nurse prescribers using patient scenarios were used as proxy methods of assessment of how nurses made their prescribing decisions.

SETTING

Two primary care trusts in the southeast of England were the settings for this study.

PARTICIPANTS

Purposive sampling to ensure there was a mixed group of prescribers was used to enable detailed exploration of the research objectives and to obtain in-depth understanding of the complex activities involved in nurse prescribing.

METHODS

Interviews and case scenarios. The use of cognitive continuum theory guided the analysis.

RESULTS

The majority of participants were unable to identify the issues involved in all the scenarios; they also failed to provide an acceptable solution to the problem, suggesting that they would refer the patient to the general practitioner. A similar number described themselves as 'very confident' while seven participants felt that they were 'not confident' in dealing with medication issues, four of whom were practising prescribing.

CONCLUSIONS

The effects of social and institutional factors are important in the decision-making process. The lack of appropriate pharmacological knowledge coupled with lack of confidence in prescribing was demonstrated. The scenarios used in this study indicate that nurses are perhaps knowledgeable in their small area of practise but flounder outside this. Further research could be conducted with a larger sample and with more scenarios to explore the decision-making and the pharmacological knowledge base of nurse prescribers, particularly in the light of government policy to extend prescribing rights to non-medical prescribers, including pharmacists.

A review of the activity and effects of nurse-led care in diabetes

AIMS AND OBJECTIVES

To identify systematically, summarize and critically appraise the current evidence regarding the activity and effects of nurse-led care in diabetes.

BACKGROUND

A diverse range of nurse-led models of care exist in diabetes. Primary studies have been conducted evaluating these models, but review and synthesis of the findings from these studies has not been undertaken.

METHOD

Systematic searches of CINAHL, MEDLINE and British Nursing Index from 1996 until June 2006. The searches were supplemented by an extensive hand search of the literature through references identified from retrieved articles.

RESULTS

Twenty-two relevant publications were identified and included findings from both primary and secondary care. The evidence indicates that nurses are involved in specific areas of care including education, individualized care, patient safety, promotion of self-care, acquisition of physical skills and psychological support. Improved glycemic control, diabetic symptoms, cost-effectiveness and decreased length of hospital stay are the main benefits of nurse-led interventions in diabetes care. Disease management protocols are the main mechanism by which nurses adjust and titrate medicines for patients with diabetes. Patient evaluations of nurse-led care report improved self-care and patient knowledge.

CONCLUSIONS

Findings of the review are generally positive. However, there are methodological weaknesses and under researched issues e.g. poor descriptions of the nurse interventions, the educational needs of nurses and the prescription of medicines by nurses for patients with diabetes, that point to a need for further rigorous evaluation.

RELEVANCE TO CLINICAL PRACTICE

Nurse-led care is an integral element of the diabetes service offered to patients. This review highlights the effect of this care and the issues that require consideration by those responsible for the development of nurse-led models in diabetes care.

Effectiveness of the nursing programme 'Coping with itch': a randomized controlled study in adults with chronic pruritic skin disease

BACKGROUND

The nursing programme 'Coping with Itch' aims at reducing itch and at helping patients with chronic pruritic skin diseases cope with itch. The programme consists of educational and cognitive behavioural interventions. Dermatology nurses carry out the programme, which supplements standard medical treatment given by a dermatologist, in individual sessions at a nurse clinic organized by the dermatology outpatient department.

OBJECTIVES

To evaluate the effectiveness of the nursing programme 'Coping with Itch' in patients with chronic pruritic skin diseases.

METHODS

A randomized controlled study was carried out. Patients with chronic pruritic skin diseases were randomly assigned to the intervention group or the control group. The intervention group received standard care from a dermatologist and nursing care according to the programme 'Coping with Itch' for a mean of 2.9 visits. The control group received usual care from a dermatologist. Data collection took place at baseline, at 3 months (t1) and at 9 months (t2) after baseline. Most visits to the nurse clinic took place during the first 3 months of the study. Main outcome measures were the frequency and intensity of itching and scratching, itch-related coping, and skin-related and general psychosocial morbidity. Secondary outcome measures were the number of visits to the dermatologist and the use of medication and ointments. Mann-Whitney tests and analyses of covariance were used to analyse differences between the two groups.

RESULTS

Data on 29 patients in the intervention group and 36 patients in the control group were used in the analyses. A trend to significance (P = 0.07) was shown in the difference between the two groups in the frequency of itching and scratching at t1. A significant difference (P = 0.04) was shown between the two groups in catastrophizing and helpless itch-related coping at t1. No significant differences were revealed at t2 between the groups. Patients in the intervention group visited the dermatologist significantly less frequently during the intervention period than did control group patients.

CONCLUSIONS

The nursing programme 'Coping with Itch' led to a reduction in the frequency of itching and scratching and to a reduction of catastrophizing and helpless coping in patients with chronic pruritic skin diseases during the period immediately following the intervention. We suggest further follow-up visits to the itch clinic to extend these results over a longer period.

Independent extended nurse prescribing for patients with skin conditions: a national questionnaire survey

AIM

To examine the prescribing practices of independent extended nurse prescribers for patients with skin conditions.

BACKGROUND

Nurse-led services are one means of improving healthcare provision for dermatology patients. The advent of nurse prescribing should optimize the role of the nurse in these situations. Medicines for skin conditions constitute a significant category within the Nurse Prescribers Extended Formulary. The impact and activity of independent extended nurse prescribing for patients with skin disease has yet to be evaluated.

METHODS

A convenience sample of 638 qualified independent extended nurse prescribers self completed a written questionnaire. spss and splus were used for data entry and analysis.

RESULTS

The majority of nurses (89.7%) were based in primary care and worked in general practice. Four hundred and seventy-six (75%) participants held a degree level qualification or higher. Forty-four (6.9%) held a diploma, degree or master's level module/s in dermatology, 433 (67.9%) had undertaken study day/s in dermatology. Five hundred and sixty (87.8%) had more than 10 years postregistration nursing experience. A significantly broader range of skin conditions, and more items for these conditions, were prescribed by nurses with higher academic qualifications, nurses with specialist dermatology training (i.e. a diploma, degree or master's level module in dermatology or dermatology study days), nurses over 45 years and nurses in general practice. A small number of nurses felt unconfident in their prescribing practice.

CONCLUSION

The majority of nurses treating skin conditions work in general practice, are highly qualified, and have a wealth of clinical experience. Nurses' dermatology training is inconsistent A small number of nurses feel unconfident in their prescribing practice.

RELEVANCE TO CLINICAL PRACTICE

Nurses prescribing for skin conditions must be provided with appropriate dermatological training in order to treat the enormous numbers of patients with skin conditions treated in primary care.

Map of dermatology: 'first-impression' user feedback and agenda for further development

BACKGROUND

Map of Dermatology (http://healthcybermap.org/dermap/) is a free web resource that enables users to search for images of skin conditions by body region and morphology rather than by condition name, which is much more useful and natural in answering questions about unknown clinical presentations/diagnoses, especially for non-specialists.

OBJECTIVES AND METHODS

This paper presents responses received from twelve users, including specialist dermatologists, non-specialists (some with interests in health informatics), and lay persons, who provided their 'first-impression' feedback on Map of Dermatology by responding to a very short e-mail questionnaire covering service usefulness and interface usability. The paper also provides a brief review of the gaps in current online dermatology information service provision in general.

RESULTS

The overall user feedback received was very positive. An exploratory discussion of the arguments and possibilities for radically improving Map of Dermatology to produce 'the ultimate web-based dermatology diagnostic tool' is also provided, together with some desiderata and preliminary 'design and feature specifications' for such a tool based on users' suggestions, the gaps highlighted in other existing online dermatology tools, and the author's own reflections and experience.

CONCLUSIONS

When successfully developed, the proposed tool is expected to have significant potential for efficiently and effectively addressing many of the currently unmet educational needs of clinicians.

Preparing nurses to prescribe medicines for patients with dermatological conditions

BACKGROUND

From Spring 2006, independent extended nurse prescribers in the United Kingdom will be able to prescribe any licensed medicines except controlled drugs. Supplementary nurse prescribers are currently able to prescribe any medication. No other country in the world has such extended prescribing rights for nurses. Aspects of prescribing viewed positively by nurses include continuity of care, increased satisfaction, and the belief that patients receive improved information about prescriptions. There is some evidence, however, that nurses feel ill-prepared to prescribe due to poor understanding of pharmacology, physical assessment and diagnosis.

AIM

This paper reports a study assessing the extent to which independent extended supplementary nurse prescribers feel prepared to prescribe medicines for patients with dermatological conditions.

METHODS

A convenience sample of 1187 qualified independent extended supplementary nurse prescribers was sent a postal questionnaire. A total of 868 completed questionnaires was returned, and 638 of these nurses prescribed medicines for skin conditions. The data were collected in 2005.

RESULTS

A total of 605 (94.8%) participants used independent extended prescribing and 234 (36.7%) supplementary prescribing. The majority were highly experienced and worked in primary care. In general, their prescribing programme had met their needs when prescribing medicines for patients with dermatological conditions. However, the needs of those who had undertaken a diploma-level module in dermatology and/or dermatology study days, and those working in both primary and secondary care, were met to a statistically significantly greater extent during the programme than for those nurses without this preparation, or those working in either primary or secondary care.

CONCLUSION

Independent extended supplementary prescribing has extended the role that nurses in the United Kingdom are able to play in the management of skin disease. Specialist dermatology training is a prerequisite for nurses adopting this role. Further evaluative work on patient-focused outcomes, i.e. accessibility and convenience of care, and satisfaction with quality of care, is required.