Primary Care Pharmacy November 1999 Vol 1 No 1 p20-21

Nursing view

Practice based pharmacists: Do patients and primary health care teams benefit?

By Christine Duthie, BSc, RGN

They do, provided that the rest of the practice team is willing to cooperate

Downfield Surgery, Dundee, is an urban practice with four full-time general medical practitioners. It has patients from all social groups. The practice of 6,500 patients employs seven practice nurses. The team comprises a nurse practitioner who runs a minor illness clinic, four experienced practice nurses whose extended roles cover nurse-led asthma, diabetes, menopause, chronic obstructive pulmonary desease, epilepsy, travel and coronary heart disease clinics. Two health care assistants further complement the team.
There is an extended primary care team which includes physiotherapists, an occupational therapist, a chiropodist, community mental heath nurses and a community care co-ordinator. When a practice based pharmacist joined the team as part of a research project funded by the Scottish Office^1,2, the nursing team had no preconceived ideas of their role and were keen to see how this would develop.

Benefits of teamwork

The value of teamwork in primary health care has been recognised for several years. Benefits include improved continuity and co-ordination of care, appropriate use of rare skills and greater job satisfaction.³ It has also been suggested that a team approach is more likely to engender creativity and so will produce a variety of potential solutions to a problem.⁴ It is important that new developments take place in a team which is willing to move traditional boundaries where innovation is viewed as an opportunity and not a threat. Learning to work together is fundamental in getting true teamwork started. From the outset the views of the nurses were sought and they shared in the decision making process.
Potential difficulties were overcome by team building exercises at practice awayday and study afternoons resulting in a free flow and exchange of information. Sharing the same client group is also beneficial as it provides common ground. Gaps in services had been identified and in-house clinics were developed for patients with chronic pain, an anticoagulantion and testing and managing Helicobacter pylori. Although these are pharmacist led, there are opportunities for the practice nurses to participate and increase skills and knowledge in these areas. It quickly became apparent to the nursing team that the inclusion of a practice based pharmacist provided an opportunity to co-ordinate and manage aspects of care of patients with a variety of diseases and conditions.

Review of medication and repeat prescription review

While a nurse might specialise in the management of a specific chronic disease or condition, in consultation with the pharmacist she can consider how a patient's medication impinges on any co-existing medical conditions. An example where this worked successfully was at the angina management clinic. This clinic addresses the care of patients presenting with symptoms of angina. Many patients on angina medication had not attended the GP for a number of years and required review. Working together, the pharmacist and the nurse identified that a number of patients could benefit from changes in medication, including the addition of low dose aspirin, and follow up at the clinic. Our over-75s were invited to take part in a four-week programme; once again the nurse and pharmacist collaborated and reviewed their medication. Patient information leaflets have been devised, covering a range of drugs. They explain in simple terms how the medication works, the benefits and potential side effects.

Pharmacist input was useful during medication reviews

Storage of medicines

Ordering, storage, prescribing, use and disposal of medicines are subject to stringent controls in hospitals. In general practice, such procedures are often left to local discretion with no one health professional having overall responsibility. This raises issues surrounding security, economy and patient safety. A lack of controls within the surgery was identified, so the senior nurse and pharmacist developed standards which were then monitored. A consequence of a safe and secure handling audit has been the implementation of nurse managed central storage of medicines within the surgery and withdrawal of all medicines from the doctors consulting rooms.⁵

Development of protocols

Different health care professionals use different approaches when changing clinical practice; these approaches can be based more on beliefs than on scientific evidence.⁶ In light of the move towards evidence based practice, the nursing team was keen to develop protocols for certain common conditions. Preliminary research was carried out by the pharmacist who determined if guidelines were credible and current. Consensus was reached between pharmaceutical, nursing and medical staff and protocols were developed in conjunction with the whole team.
Developing protocols in this way gave us the advantage of being able to tailor recommendations for practice to the local situation and patient population. One area where this proved immensely valuable was in wound care. At present there are a vast number of dressings products from which to choose. It is important that this decision is based upon a holistic assessment of the patient and the wound. Practising nurses are accountable for their actions and so the choice of dressing product should be based upon research based evidence and not ritualistic practice.⁷ Effective management of wounds requires an understanding of the staging of wounds, factors involved in wound healing and a knowledge of dressings and treatments which might be used to assist the healing process. A joint teaching programme was established for all practice and district nurses.
Implementation of the protocol resulted in improved assessment, documentation and communication between nursing staff.

Conclusion

As the role of the practice based pharmacist expands and is adopted by other practices, it is vital that it takes place in a team which is willing to co-operate and accept them. Pharmacists possess the skills and attributes required to develop progressive and innovative primary care services. The addition of a practice based pharmacist to the team not only benefits patients but can also have a positive influence on how practice nurses develop their clinical skills and practice.

References

Mrs Duthie is a nurse practioner at Downfield surgery, Dundee