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Professions & prescribing: insights from nursing & pharmacy Paul Bissell Public Health ScHARR University of Sheffield Background Medical sociologist / worked in ... – PowerPoint PPT presentation

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Title: Professions

Professions prescribing insights from nursing
  • Paul Bissell
  • Public Health
  • ScHARR
  • University of Sheffield

  • Medical sociologist / worked in pharmacy for over
    10 years
  • Numerous evaluations community pharmacy practice
  • Advice-giving in pharmacy
  • Lay and professional perspectives on risk of
    non-prescription medicines
  • Pharmacy supply of emergency hormonal
    contraception (EHC)
  • Public health and pharmacy
  • Social capital, inequalities and pharmacy
  • Ethical dilemmas in community pharmacy
  • Medicines management in community pharmacy
  • Evaluation of supplementary prescribing in
    nursing and pharmacy

  • Nursing pharmacy professions both make claim to
    be rightful heirs to non medical prescribing.
  • Provide contrasting overlapping insights into
    sociology of professions / continuing dominance
    of medical profession around medicines usage.

Context for non-medical prescribing power of
medical profession
  • Doctors have held a unique position of power
    over prescribed medications for some years, a
    role that has brought with it the control of the
    scope of practice of other health professionals.
    It is likely that some will be reluctant to
    abandon it. (Baird 2000 454)

Context for non-medical prescribing power of
medical profession
  • The medical profession has an almost exclusive
    right to prescribe medicines but this right is
    being challenged byother health professions. It
    is argued that in British General Practice,
    prescribing is a battle ground on which the cause
    of clinical autonomy is defended. (Britten

Role of professions
  • Classic theme in medical sociology.
  • Friedsons Profession of Medicine
  • medical power rests on autonomy over its own work
    activities and
  • dominance / control over the work of others in
    the health care division of labour.

Medical Dominance
  • organised autonomy is not merely freedom from
    the competition or regulation of other workers,
    but in the case of such a profession as
    medicineit is also a freedom to regulate other
    occupations. Where we find one occupation with
    organised autonomy in a division of labour, it
    dominates the others. Immune from legitimate
    regulation or evaluation from other occupations,
    it can legitimately evaluate the work of others.
    By its position in the division of labour we can
    designate it as a dominant profession (Friedson

Medical Dominance
  • Last 30 years various arguments about decline of
    medical power
  • Proleterianization clinical freedom under threat
    from state / HMOs
  • Deprofessionalisation rise of assertive patients
    / narrowing of knowledge gap
  • Nancarrow Borthwick (2005) discuss the fluid
    nature of professional boundaries in health care

Medical Dominance
  • A consensus that medical power is being
    challenged, but not necessarily eroded
  • Internal stratification within medical profession
  • Cost awareness containment managerialism/
    audit / clinical governance
  • Greater scrutiny regulation as a result of
    medical errors / abuse
  • Consumerism / lay knowledge /greater
    assertiveness by patients
  • Professionalisation and availability of CAM
  • Lay scepticism towards expert systems more
  • Boundary encroachment from other health
    professionals (eg. prescribing and medicines
    management nursing and pharmacy)

Prescribing medicines management in nursing and
  • General consensus about a challenge to, if not an
    erosion of medical power.
  • How has the medical profession reacted to nurse
    and pharmacist prescribing / medicines management
  • Has this translated into enhanced status for
    nursing and pharmacy as a result of involvement
    in prescribing / medicines management tasks?
  • What are the implications for nursing and
    pharmacy professions?

Nurse Prescribing - overview
  • Development reaction to nurse prescribing in
    the UK and US.
  • Different experiences and responses by medical
    profession in UK and US.
  • Evidence of considerable concern from the medical

Nurse Prescribing
  • UK - able to carry out both Independent and
    Supplementary prescribing.
  • Independent prescribing began in 1994 almost
  • Roots in DN diagnosis requiring rubber stamp
    / geographical distance from doctors require to
    sign / improvements in access.
  • Strong political support for prescribing role
    from RCN alliances with BMA RPSGB / stressed
    partnership model.
  • Push for private members bill (1992 Medicinal
    Products Prescription by Nurses etc Act).

Nurse Prescribing
  • Conservative government concerned about cost.
  • June Crown appointed to carry out review of non
    medical prescribing.
  • Series of pilot sites set up rise of
    independent prescribing (from limited formulary)
  • Pace of change speeded up post Labour victory
  • Extended Independent Nurse Prescribing from 2001.
  • Dependent, renamed supplementary prescribing (via
    Clinical Management Plan) implemented.

Nurse Prescribing - responses
  • Numerous (HSR) studies, claiming nurse
    prescribing viewed positively by patients, is
    cost effective, is (viewed as) safe, improves
    access and does not waste doctors time.
  • Jones - irrefutable proof that nurse
    prescribing was working on every criteria of
    safety, costs and effectiveness.
  • By 2005 prescribing from whole formulary was
    announced (for both nurses and pharmacists) by
    Sec of State.

Nurse prescribing concerns from within
  • Lack / absence of formal supervision for nurse
  • Lack of incentives to assist with mentoring.
  • Concern that it is driven by medical shortages /
    to reduce junior doctors hours / size of medical
  • Many nurses not prescribing despite completing
  • Concern that nursing becomes medicalized / looses
    identity as a caring profession.
  • Aidroos (2002) offer and drug and depart
  • Will nurses be held to the same standards of care
    as other health professionals?
  • Do nurses have choice about whether to prescribe
    evidence that employers alter job descriptions
    to include prescribing.
  • Considerable scope to develop a sociological
    research agenda in these areas.

Nurse prescribing concerns from medical
  • BMA (2002) training nurses get is nothing like
    sufficient and will not give them the clinical
    knowledge they need to prescribe these drugs.
  • Nurse prescribing - a dangerous uncontrolled
    experiment (Horton 2002) - also refers to
    prescribing entailing a loss of nurses identity.
  • Criticism of nursing seen through lens of
    professional attributes.
  • Others more cautiously optimistic about nurse
    prescribing (Avery and Pringle 2005).
  • Concern about speed of change / availability of
    mentoring from GP / doctor / availability of
  • Medical press (eg Pulse) maintaining pressure
    surveillance over nurse prescribing.
  • Numerous concerns about pharmacology
    therapeutics training for nurses.

Safety nurse prescribing
  • Systematic review of safety of nurse
    (supplementary) prescribing.
  • Most published papers not based on empirical
    research / focus on adequacy of nurses training,
    knowledge skills.
  • Review shows that doctors believe that Clinical
    Management Plan allows them to retain power /
    provides a framework for guiding decisions.
  • Little empirical evidence that nurse prescribing
    is unsafe.
  • Concerns tempered by awareness of scope / scale
    of nurse prescribing in England.

Overview of PACT data
Nurses Nurses Nurses
Year Item volume Net ingredient cost
2004 3.5 million 52.2 million
2005 4 million 58.9 million
2006 6.3 million 79.3 million
2007 (to end of September) 6.8 million 79.5 million
Pharmacists Pharmacists Pharmacists
Year Item volume Net ingredient cost
2004 2706 25,348
2005 11,458 96,846
2006 31,052 278,634
2007 (to end of September) 44,318 332,320
Nurse PACT Data
Nurse prescribing
  • UK - establishing prescribing rights for nurses
    has involved some conflict with the medical
  • Not clear that supp rx based around CMP enhances
  • CMP provides reassurance for doctors.
  • Maintains status divisions between supp
    independent prescriber.
  • Indeterminacy / technicality ratio supp rx
    based around CMP / maintains status hierarchies.
  • Diagnosis / independent prescribing may result in
    rather more conflict.
  • Different to situation in the US.

Nurse prescribing in US
  • Development of nurse prescribing resulted in much
    more opposition in the US.
  • Nurse prescribing grew out of nurse practitioner
    role in paediatrics / response to thin provision
    of care in rural areas.
  • Creation of negative formularies for nurses /
    negotiation of independent prescribing in most
    states for NPs.

Nurse prescribing in US
  • Mundinger et al (2000) combination of authority
    to prescribe drugs, direct reimbursement from
    most payers and hospital admitting privileges
    creates a situation in which NPs and primary care
    physicians can have equivalent responsibilities.
  • NPs reimbursed at same rate as physicians in some
  • Fennell argues inherent in the physician and
    pharmacist opposition to nurse midwives
    prescribing isan interest in their own economic

Nurse prescribing in US
  • Byrne Helman (2002) anti-competitive
    practices of health plans where consumers are
    instructed to use mail order/internet pharmacy
    services, many of which refuse to accept NPs
  • Chen-Scarabelli (2002) various state medical
    associations lobby against nurse practitioners in
    a an attempt to maintain monopoly over health
    care management.

Nurse prescribing in US
  • Edgley et al federal states reactive stance
    has opened the way for overt conflict between the
    professions as they fight it out over territory,
    rights and responsibilities.
  • Professions responses to threats opportunities
    depends on organisational context.

  • Nurses successfully developed prescribing role.
  • Concerns from within nursing and from medical
  • Appears to be significantly more conflict in the
    US than UK.
  • Medical profession able to mobilise arguments
    about appropriateness of nurse training, despite
    lack of evidence about risks / dangers /
    inappropriate prescribing / consideration of type
    of prescribing being undertaken.
  • Likely that IP will evoke more conflict than SP.

Pharmacists roles in medicines management
  • Pharmacy - very different history response to
    challenges of non medical prescribing.
  • Much slower engagement with prescribing agenda.
  • IP only just getting started / several years of
  • Professional development shaped by commercial
    organisational environment (community) pharmacy
    operates in.
  • Significant barriers to (community) pharmacists
    developing role in this area.
  • Must overcome these barriers AND deal with
    potential opposition from medical profession vis
    a vis IP and SP.

Pharmacist prescribing?
  • Eaton and Webb (1979) interviewing educators
    and policy makers
  • I would draw the line at prescribing the
    pharmacist isnt trained to prescribe treatment.
  • Well really I think lines may be drawn in terms
    of the medical degreeBut they (pharmacists) will
    never be involved in prescribing, at least in
    Britain, unless they have a medical degree. You
    cant sign a prescription which somebody will

Community Pharmacy recent history
  • Up to mid C20th legitimacy based on expertise in
    compounding / producing proprietary medicines.
  • Original pack dispensing from 1960s onwards
    forced loss of role
  • Pharmacy has long history of links with commerce
    / petit bourgeoisie.
  • Ambiguous relationship with the NHS private
    provider in socialised system.
  • Community pharmacies seen as dispensing
    factories considerable professional
  • Pharmacists over qualified under utilised
    (Eaton Webb 1979) de-skilled.
  • New roles for pharmacists essentially a quest
    for survival (Edmunds Calnan 2001).

Pharmacy sociology of the professions
  • Denzin and Mettlin (1968) pharmacy viewed as a
    case of Incomplete professionalization.
  • Pharmacy lacked control over the social object
    of practice - the medicine.
  • Pharmacists guided by commercial interests at
    odds with the altruistic, service orientation of
    a profession.
  • Essentially, a highly damaging critique / retains

Pharmacy sociology of the professions
  • Dingwall Wilson (1995)
  • Critique of Denzin Mettlin (1968) position
  • Other professions (e.g lawyers) associated with
    commerce, does not undermine professional status.
  • Pharmacists transform objects (drugs medicines)
    and have a (Foucauldian inspired) role in
    surveillance around medicines usage.
  • Hibbert et al (2002) weak role over medicines
    surveillance protocol driven role undermined by
    lay expertise / consumerism.
  • Turner (1995) refers to pharmacy as tainted by
    petite bourgeoisie image.

Pharmacy sociology of the professions
  • Pharmacists increasingly corporatised
    increasingly employees rather than independent
  • Key decisions not taken by pharmacists (tensions
    between superintendents marketing departments)
    / de-pharmacisation of chains / multiples.
  • Lack autonomy over work practises / boundary
    encroachment from others.
  • Small profession (45 000 registered pharmacists
    split between hospital and community.
  • Considerable dissatisfaction with working
    practises in community pharmacy.

Re-professionalization project.
  • Plethora of policy documents PIANA, Choosing
    Health Through Pharmacy, Pharmacy in the New NHS
  • Some new roles identified
  • smoking cessation,
  • PBNX
  • supervised methadone
  • minor ailments schemes
  • Supplying emergency contraception
  • Chlamydia screening
  • NHS contractual framework for pharmacy
    essential, advanced and enhanced.
  • Prescribing and medicines management

Re-professionalization project.
  • Continuing issues in community pharmacys
    re-professionalisation project
  • Commercial environment in which pharmacy is
  • Limited autonomy as employees
  • Patient doubts about appropriateness of community
    pharmacy as a site for advice / medicines
    management / prescribing?
  • Isolation from other professions / policy arena
  • Subordination

Community Pharmacy Medicines Management Project
  • Project developed / implemented by the
    Pharmaceutical Services Negotiating Committee
  • Funded by DoH (2001-2004)
  • Aim to evaluate the introduction of a community
    pharmacy led medicines management service for
    patients with coronary heart disease (CHD)
  • Evaluated by independent research team using RCT
    qualitative research
  • University of Aberdeen
  • University of Nottingham
  • Keele University

Results- appropriateness
Intervention Baseline Intervention Follow up Control Baseline Control Follow-up P-value
Aspirin 82 80 76 78
Aspirin-related 95 94 91 93 0.24
Target cholesterol 59 58 57 55 1.00
Statin 73 79 68 77
BP 47 49 43 47 0.49
  • Qualitative interviews and focus groups with
    doctors, pharmacists and patients sheds
    considerable light on ways in which the doctors
    and pharmacists are working together?
  • Informs a sociology of pharmacy.

Pharmacists views about medicines management
  • Very positive about service
  • Its wonderful to be able to talk to people
  • Better patient care
  • Were getting closer to some of the patients
    because they thinkfeel that youre taking more
    of an interest in them rather than oh, another
    customer! (P11/FG3)
  • Using clinical skills
  • It certainly is an extension of our role and a
    very worthwhile one, actually using our clinical
    skills for a change. (P16/FG4)

Pharmacists concerns GPs perceptions of their
subordinate status
  • We work as a team but they (GP) think theyre
    the upper class we are the lower class you know
  • They sort of think ofthey still think that a
    pharmacist is a class down, like you know you
    think of a shopkeeper. (P14/FG7)
  • Because theyre not used to having their
    judgement questionedNot by someone that they
    perceive as being a shopkeeper. (P12/FG4)

Pharmacists concerns GPs feeling threatened
  • I think its because they feel threatened its
    human nature isnt it? You are impinging on their
    territory. (P34/TI1)
  • They might feel their opinion is being
    challenged, that they are being checked upon, or
    whatever because I suppose they are not used to
    it. It is a new thing for them really to have
    someone who is looking at the notes they have
    done themselves. (P09/FG2)

Commerce Pharmacy
  • GPs concerned that community pharmacists advice
    influenced by commercial factors
  • The difficulty I have really is trying to be
    certain that their advice is not commercially
    related (GP19)
  • Resulted in GPs being suspicious of the clinical
    advice they received from community pharmacists.

Access to Medical Records
  • I think the whole area then that opens up is
    all the areas of confidentiality and people who
    are not actually part of the GP primary care
    team, who have access to confidential medical
    records, which may include so and so is having an
    affair with so and so, who might happen to be the
    pharmacists neighbour you know. It may not, its
    a most unlikely scenario but our duty first and
    foremost is to all our patients is
    confidentiality. (GP15)

Pharmacists Changing Patients Medication
  • Concerns about whether it was appropriate for
    community pharmacists to change patients
  • Do community pharmacists know patients well
    enough to undertake this service?
  • Pharmacists involvement could cause fragmentation
    over patient care responsibility
  • Patients could become confused if more than one
    person had responsibility for medication
  • Pharmacists lack access to medical records when
    undertaking medicines management role

Pharmacists Changing Patients Medication
  • I mean I think getting medication right is
    quite complicated and it depends on quite a lot
    of medical historical information and unless they
    have got the whole set of notes and they are
    sitting down with the patient and got to know
    them over a period of time they cant do that
  • Likely to be highly relevant to prescribing.

Reasons for GPs Concerns
  • Professional boundaries
  • Threateningchallenging management and
  • The whole area opens up areas of confidentiality
    and people who are not actually part of the
    primary care team

  • Strong support for CPMMP in some areas, GPs
    highlighted many concerns
  • Community pharmacists links with commerce
  • Some resistance to pharmacists undertaking new
    roles boundary encroachment
  • Some resistance to community pharmacists having
    access to patients medical records
  • Distance from patients - concerns that
    pharmacists do not possess a detailed knowledge
    of the patient clinical histories
  • Isolation from medical / nursing professions and
    primary care more generally.

Medicines Management A challenge to medical
  • Issues identified by Denzin Mettlin (1968)
    still relevant commerce / altruism /
  • Strong discourse around community pharmacys
    subordinate position in health care division of
  • Distance from patients everyday care.
  • GPs able to mobilise powerful arguments against
    pharmacists involvement. Eg commerce, access to
    records, confidentiality, knowledge of patient.
  • Able to name / identify roles for pharmacists eg.
    compliance / repeat dispensing but NOT changing
  • Pharmacists collude to re-produce and sustain
    their own subordinate status. Eg. reference to
    shops deference to GPs.

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

Medicines Management patients views
  • Commercial influences
  • Im just not sure Im happy about it at all. I
    enjoyed talking to him, that wasnt the problem.
    Its just at the back of your mind, is it me, or
    is it a bit daft, you wonder about, well, you
    wonder about the drugs companies and all that,
    and all those promotions in the shopI came home
    from it, and we were talking, I said, is it the
    kind of place they should be doing this kind of
    thing? (R5)

Medicines Management patients views
  • Subordinate position
  • The pharmacists dont diagnose, dont they? The
    doctors do that. They put you on the treatment
    and the pharmacist just gives you it.
  • Because you look at most prescriptionsIt says
    if you develop any of the following consult your
    GP. And this is from the chemical company. They
    dont say go to the pharmacist. They say go to
    the doctor.

Subordination isolation
  • Coopers research around ethical loneliness of
  • Draws on qualitative research with pharmacists
  • Subordinate position
  • I tend to feel that when I get a prescription,
    coming back to your point, that its the doctors
    responsibility ultimately and that Im just a
    tool of the doctor really. Im not happy with it,
    Im passing the buck and not accepting the
    responsibility that I should be taking.

Subordination isolation
  • Isolation
  • In a way we are isolated as pharmacists and we
    havent got anyone to chat to, to ask about
    things, to find out what other pharmacists
  • Were all islands and were all competing
    against each other The only time when you
    come into contact with another pharmacist is when
    theres a conflict with something or when you
    want to borrow something.
  • Habermas / Mead (discourse ethics) loneliness /
    isolation may be ethically problematic for

A sociologically informed research agenda for
  • Commerce, altruism, isolation, subordination
    retain some force.
  • Nancarrow Borthwick (2005) not clear that
    taking on new roles results in enhanced status.
  • Moreover no examples of role changes that have
    removed the attributes that are associated with
    the professional labels.
  • Community pharmacy remains a site tainted by
    commerce, isolation, subordination.
  • To develop, pharmacists leave the commercial
    environment / undertake professional journeys /
    narratives of change.

Prescribing medical dominance?
  • Britten (2001478) Prescribing and the defence
    of clinical autonomy
  • The medical profession has an almost exclusive
    right to prescribe medicines, but this right is
    being challenged by the State, patients and other
    health care professionalsThese changes do not
    yet support the thesis of proletarianization or
    deprofessionalization as the medical profession
    continues to dominate the clinical agenda and
    responsibilities of other health care workers.
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