As a British overseas territory, Gibraltar enjoys a unique position in Europe. Healthcare services are provided by the Gibraltar Health Authority (GHA) to approximately 35 000 residents and the healthcare model is closely based on that of the UK. In Gibraltar, as in the rest of the world, there is little consensus on the definition or scope of the specialist nurse (Cannaby et al, 2020). However, the authors' current palliative nurse specialist role may be comparable with that of a nurse practitioner role in the UK, which is defined by meeting four pillars of advanced competence and practice: clinical practice, leadership and management, education and research (Royal College of Nursing (RCN), 2018; Health Education England et al, 2020; Care Quality Commission, 2021). The two palliative nurse specialists employed by the GHA cover both acute and community sectors and practise with no palliative consultant input, although a part-time palliative doctor joined the team towards the end of the first year of independent nurse prescribing.
In 2018, the law in Gibraltar was changed to allow appropriately qualified registered nurses to prescribe within their area of competence. The law currently only allows registered nurses employed by the GHA to be non-medical prescribers. The acronym INP (independent nurse prescribing) will be used throughout this article.
Both of the palliative nurse specialists employed by the GHA completed the first non-medical prescribing course delivered by the Faculty of Health, Social Care and Education of Kingston University and St George's University of London in collaboration with the Gibraltar School of Health Studies. The two palliative independent nurse prescribers now issue prescriptions across the acute and community sectors in Gibraltar. All prescriptions are recorded for audit purposes and 2020 was the first complete year of recorded prescriptions. A preliminary audit review of the recorded prescription data highlighted two primary areas of impact—facilitating end-of-life care at home and anticipatory prescribing for end-of-life care.
Nurse prescribing in specialist palliative care
Palliative care is defined as the active holistic care of people with advanced, progressive illness (National Institute for Health and Care Excellence (NICE), 2021). Specialist palliative care services manage complex palliative care problems that cannot be dealt with by generalist services (NICE, 2021). Cicely Saunders, the founder of the modern hospice and palliative care movement, wrote that such patients require ‘total care’, described as care that addresses psychological and spiritual needs, as well as pain and other symptoms. This holistic approach may be described as being at the heart of palliative care, which seeks to address these needs as a whole rather than in isolation (Saunders, 2003). The role of the palliative nurse specialist is particularly suited to this integrated approach, assessing and managing needs from a holistic perspective.
Challenges currently facing palliative care services include growing demand due to demographic changes and reduced resources (Hospice UK, 2013; Davies et al, 2014; Sleeman et al, 2016), as well as changes to funding structures in healthcare (Cummings and Bennett, 2012). In this context, increasing the autonomy, flexibility and skill set of palliative specialist nurses may be increasingly relevant, in not only improving symptom management and patients' quality of life, but also potentially increasing the efficiency of palliative services (Salamanca-Balen et al, 2018; Latter et al, 2020). It has been suggested that nurse prescribing lies at the intersection of medicine and nursing and that it may detract from the holistic underpinnings of nursing (Clegg et al, 2006; Creedon et al, 2015; Ross, 2015). However, in practice, INP appears to enable palliative nurse specialists to have a much greater degree of autonomy and flexibility in responding to patients' needs, bringing specialist knowledge and experience to holistic symptom management. In the UK, recent research suggests that patients' access to palliative medicines and control of their symptoms could be improved by increasing non-medical prescribing in palliative care (Latter et al, 2020). In Gibraltar, the introduction of palliative INP appears to support this finding. Palliative INP has facilitated advanced practice, particularly when managing the symptoms of actively dying patients who are unable to express their needs and rely on expert assessment. INP allows the specialist nurse to prescribe accordingly, evaluating the effects to inform clinical decision-making and further prescribing.
Effective and timely access to medication is vital in ensuring high-quality end-of-life care (NICE, 2017) and the introduction of INP in Gibraltar has expedited patients' access to medication at the end of life. This is similar to findings in the UK and Ireland, which suggest that the introduction of INP gives nurse specialists increased autonomy and greater efficiency in symptom management and improving care (Ryan-Woolley et al, 2007; Courtenay et al, 2012; Creedon et al, 2015; Lennon and Fallon, 2017; Latham and Nyatanga, 2018). Independent nurse prescribers are thus able to provide more comprehensive and autonomous care that subsequently increases job satisfaction (Lennon and Fallon, 2017; Hall et al, 2020) as well as improving quality of care, service efficiency and improved patient communication and other outcomes (Stenner and Courtenay, 2008; Courtenay et al, 2012; Lennon and Fallon, 2017). The introduction of palliative INP in Gibraltar appears to have similarly improved symptom management, increased the efficient use of resources and facilitated patients being cared for in their preferred place at the end of life.
Facilitating end-of-life care at home
In Gibraltar, as in many other countries, most people die in hospital (Broad et al, 2013). It is unclear if this is due to patient preference as there is currently a lack of recorded data in Gibraltar identifying preferred place of end-of-life care. Identifying and facilitating a person's preferred place of end-of-life care is an important part of delivering high-quality care (Department of Health, 2008; Leadership Alliance for the Care of Dying People (LACDP), 2014; National Palliative and End of Life Care Partnership, 2015). It may be that a significant number of people would prefer to die at home. However, this may only be preferable if their symptoms are managed effectively and they are well cared for; issues surrounding symptom control often lead to patients entering hospitals at the end of life (Woo et al, 2006; Shucksmith et al, 2013; Hoare et al, 2015).
Since the introduction of palliative INP in Gibraltar at the end of 2019, the number of end-of-life care cases at home has increased significantly (Table 1). This may be due to a variety of factors, including the impact of COVID-19 on patients' decisions to receive end-of-life care at home rather than entering hospital. However, the impact of palliative INP is also notable, facilitating 73% of all home end-of-life care cases in 2020 and 82% of cases in 2021 (Table 1). Timelier symptom management by specialist clinicians (Dawson, 2020) has proved effective in supporting people to die in their preferred place for end-of-life care.
Table 1. Palliative independent nurse prescribing for patients requiring end-of-life care at home
| Year | End-of-life care patients* at home (total per year) | Number of patients (n), prescribed for by a palliative independent nurse prescriber during last week of life (% of total home cases) |
|---|---|---|
| 2018 | 11 | - |
| 2019 | 12 | - |
| 2020 | 26 | 19 (73%) |
| 2021 | 33 | 27 (82%) |
In Gibraltar, patients at home remain the responsibility of their GP and the district nursing team. The district nursing team manage end-of-life symptoms using prescribed medication and operate equipment such as syringe drivers in the patient's home. Syringe drivers are pumps that deliver a continuous dose of a particular drug or combination of drugs and are typically used when a person is unable to take medication orally, for example to manage symptoms at the end of life (LACDP, 2014).
As independent nurse prescribers, the palliative nurse specialists were able to make critical prescribing decisions in the patient's home that prevented hospital admissions. Examples of these decisions included commencing a syringe driver (60% of all patients prescribed for by palliative independent nurse prescribers were prescribed medication via a syringe driver (see Table 2) or prescribing a dose of medication for immediate symptom control. This again echoes findings in the UK literature; a significant benefit of palliative INP is rapid and effective symptom management at the end of life in the community (Latham and Nyatanga, 2018)
Table 2. Palliative independent nurse prescribing summary
| Patients' place of palliative care | 2020 | 2021 |
|---|---|---|
| Total number of prescriptions | 473 | 709 |
| Total number of patients prescribed for | 77* | 129* |
| At home | 30 | 53 |
| Surgical ward | 30 | 26 |
| Medical ward | 26 | 57 |
| Critical care unit | 6 | 9 |
| Residential care | 2 | 2 |
| Total number of patients prescribed anticipatory end-of-life medications (across all settings) | 42 | 53 |
| Total number of patients prescribed for via CSCI (across all settings) | 46 | 46 |
Key: CSCI=continuous subcutaneous infusion
In addition to facilitating patient preferences regarding their preferred place of care and improving end-of-life symptom management in a home setting, other benefits in the community setting include effective resource management. GP visits in 2020 were greatly reduced in the last weeks of life for patients who received end-of-life care at home. By reducing GP workload and preventing unnecessary hospital admissions, finite resources can be targeted more appropriately (Dowden, 2016; Steventon, et al, 2018).
Anticipatory prescribing for end-of-life symptom management
The second area of significant impact noted during the preliminary audit review was that of anticipatory prescribing for end-of-life symptom management. Recognising the dying phase is extremely important as it allows clinicians to plan and communicate care effectively (LACDP, 2014). The role of the palliative nurse specialist is particularly relevant in this context and part of planning end-of-life care is ensuring appropriate medications for symptom management are prescribed in advance.
Prescribing anticipatory or ‘just in case’ (NHS Scotland, 2014) medication for end-of-life symptom control can reduce delays in administering medication and thus prevent exacerbation of distressing symptoms (NICE, 2017). During the first year of palliative INP, a significant part of practice involved prescribing in anticipation of the five main symptoms commonly related to the dying person, namely pain, breathlessness, nausea, agitation/distress/delirium and secretions (NICE, 2021). Fifty-five per cent of the patients who were prescribed medication by the palliative independent nurse prescribers were prescribed anticipatory end-of-life medication (see Table 2).
The introduction of palliative INP increased the recognition and identification of gaps and inconsistencies in existing anticipatory prescribing practice. This prompted the development of the ‘GHA Anticipatory Prescribing Guidelines for Symptom Management at End of Life’ in 2020. Palliative INP and the dissemination of the guidelines appear to have resulted in an increase in effective anticipatory prescribing, and this increase is the subject of ongoing audits and evaluation.
Effective anticipatory prescribing has prompted earlier recognition of the dying phase, improved symptom management and also empowered nursing colleagues to exercise their clinical judgement in using prescribed medication to manage patients' symptoms at end of life.
The empowerment of nursing colleagues is particularly relevant in the context of cultural misconceptions surrounding opioids. These misconceptions are related to addiction and side effects such as respiratory depression, and exist in Gibraltar as in some other European countries (Maltoni, 2008; O'Brien et al, 2017; Arias-Casais et al, 2019.
Uptake of non-medical prescribing
Although the UK has led the way regarding the introduction of non-medical prescribing (Cope et al, 2016) uptake appears to be inconsistent, and a significant proportion of non-medical prescribers in the UK as well as Ireland do not use their qualification (Lennon and Fallon, 2017; Graham-Clark et al, 2018). It may be helpful to consider the facilitators and barriers to the introduction of the role in Gibraltar in this context, however, transferability of findings may be reduced due to the very specific and limited nature of services in Gibraltar.
Barriers to palliative INP
In the UK, common barriers to palliative INP practice include difficulty accessing patients' notes, anxiety surrounding errors, lack of knowledge, lack of support and lack of access to continuing professional development (Quinn and Lawrie, 2010; Latham and Nyatanga, 2018; Dawson, 2020). Inter-professional pressure and unfavourable attitudes from other professionals have also been described as significant barriers (McBrien, 2015; Dowden, 2016; Latham and Nyatanga, 2018; Dawson, 2020). During the first year of palliative INP in Gibraltar, barriers were primarily related to the introduction of a new advanced nursing role into an established medical paradigm.
In the UK and Ireland, there has been extensive discussion in the literature regarding initial concerns surrounding the introduction of non-medical prescribing (Avery and Pringle, 2005; Lockwood and Fealy, 2008). However, these concerns seem to have reduced over time (McGleish et al, 2015; Lennon and Fallon, 2017), perhaps due to increased evidence supporting the safety and efficacy of independent nurse prescribers (Carey et al, 2014; RCN, 2014; Creedon et al, 2015).
The impact of INP on professional boundaries, the struggle for dominance (Fisher, 2010; Cooper et al, 2012) and the complexities surrounding the blurring of roles and responsibilities arising from the introduction of INP are common themes in the UK literature (Kroezen et al, 2014; Dowden, 2016). In Gibraltar, the introduction of palliative INP caused similar changes and complications.
The ongoing complexities inherent in the relationship between independent nurse prescribers and the medical profession are still apparent both internationally (McBrien, 2015; Lim et al, 2017) and in the UK (Kroezen et al, 2014; Creedon et al, 2015) and this is likely to be the case in Gibraltar for some time. However, several factors that ameliorated the effects of the transition were identified during the first year of palliative INP.
Facilitators
Comprehensive record keeping and documentation
In 2019, the Royal Pharmaceutical Society's A Competency Framework for All Prescribers (2016) replaced the Nursing and Midwifery’ Council's (NMC) Standards of Proficiency for Nurse and Midwife Prescribers (2006) and both form the basis for INP practice in Gibraltar. Both competency frameworks emphasise the importance of recording for data analysis and auditing non-medical prescribing practice. In line with prescribing policy in Gibraltar, the palliative independent nurse prescribers recorded the details of every prescription and medication prescribed, with an accompanying rationale and any further relevant information. This comprehensive documentation provided a thorough record to present to Gibraltar Health Authority's Drugs and Therapeutics Committee when navigating professional challenges to the new role.
Anticipatory prescribing guidelines
The first year of prescribing practice highlighted the importance of anticipatory prescribing as well as the existing gaps. This was particularly relevant in the hospital setting. As in the UK, where junior doctor staffing for small hospitals is complex and entails rapid turnover of staff (Clegg et al, 2006), Gibraltar has a high turnover of junior hospital doctors, which can sometimes lead to variability in prescribing, particularly in palliative care. Independent nurse prescribers have an opportunity to influence local prescribing policy and to promote evidence-based practice (Stenner et al, 2010). In Gibraltar, guidelines on anticipatory prescribing for end-of-life symptom management were developed and disseminated by the palliative specialist nurses during their first year of INP. These (unpublished) guidelines facilitated palliative INP in several ways: standardising anticipatory prescribing practice, providing a teaching tool and highlighting the palliative nurse specialists' scope of INP practice.
Collaborative working
Gibraltar is a relatively small and closely linked community and this is likely to have enhanced communication and the development of professional relationships that were instrumental in facilitating the introduction of palliative INP. The strength of existing relationships with the wider multidisciplinary team (MDT) greatly facilitated understanding and appreciation of the new palliative INP role and its specialised palliative prescribing approach.
Although there were some challenges surrounding the introduction of the role, overall, collaborative working appears to have been enhanced by the palliative independent nurse prescriber role. Nurse prescribing has the potential to improve team working (Stenner et al, 2010), particularly between palliative specialist nurses and GPs (McGleish et al, 2015) and this effect was apparent with local GPs and district nursing teams as evidenced by the increase in end-of-life care provided at home (see Table 1). However, this effect was also evident in the hospital, particularly in the surgical setting: 39% of patients prescribed for by palliative independent nurse prescribers in 2020 were on a surgical ward, which is the same amount of patients prescribed for at home that year (see Table 2). These findings vary slightly from some UK studies, which show that most palliative INP prescribing takes place in the patient's home (Ziegler et al, 2015) and most nurse prescribing generally occurs in primary care settings (Courtenay et al, 2012). This close collaboration between the surgical and palliative teams may be unique to Gibraltar and requires further exploration.
Specialisation and prior experience
Significant prior experience is a key determinant in nurses successfully implementing and sustaining their INP practice (Courtenay and Berry, 2007; Courtney et al, 2012) and confidence in their area of specialty has been found to be particularly important (Cope et al, 2016). Nurse prescribing may be perceived as safer when carried out by an experienced nurse, and advanced clinical skills and knowledge are required to make appropriate prescribing decisions (Scrafton et al, 2012). These findings were echoed in Gibraltar. Extensive prior experience in the palliative specialist role and familiarity with advanced symptom management provided confidence and the ability to communicate clearly and positively about prescribing decisions.
Support
Support for the prescribing role has been found to be a primary factor affecting non-medical prescribing in the UK (Courtenay et al, 2012). Genuine engagement and support from management are some of the most important factors enabling new practitioners to succeed (Stenner et al, 2010; Cooper, 2015). In Gibraltar, this type of support was found to be equally important. Throughout the first year of palliative independent nurse prescriber practice, access to senior management supported effective navigation through the various challenges, as well as disseminating the anticipatory prescribing guidelines, which in their turn facilitated palliative INP.
Findings from a nurse-led hospice unit in the UK suggested that mutual support and critical analyses of practice are fundamental in facilitating palliative INP (Dawson, 2020). Locally, this type of peer support is equally valuable and involves structured, regular independent nurse prescriber meetings as well as ongoing informal peer support and feedback sessions with the wider MDT. Other sources of support come from doctors, pharmacists and the prescription advisory service as well as UK linked professional development sessions.
Impact and recommendations for future practice
The findings from this preliminary review of the first year of palliative INP clearly show that further research and audits are needed. The audit process has the potential to guide policy and organisational objectives linked to improving patient care (McCance et al, 2012). The process of recording prescriptions is sometimes considered time consuming and to reduce the time available to spend on patient interaction by nurse prescribers (Creedon et al, 2015); however, recording prescribing data for audit purposes provides valuable insight into the rapidly changing nature of palliative care and the specialist role, as well as its impact on patients and families.
Measuring quality in palliative care can be complex due to the vulnerability of the patient population (Visser et al, 2015; Khalil et al, 2020) and auditing independent nurse prescriber practice may be a relatively non-invasive and effective way of evaluating and improving practice
Conclusion
Palliative care aims to address the physical, psychological and spiritual needs of a person and their family, particularly at the end of life. In order to do this effectively, expert and timely symptom management is fundamental. Palliative specialist nurses are well positioned to address these needs using a specialised and holistic approach. INP increases the specialist nurses' autonomy and their ability to use their skills for complex, holistic symptom management.
Nurse prescribing in Gibraltar was introduced in 2019 and has had a significant impact on the delivery of palliative care services. Initial benefits appear to include facilitating end-of-life care at home and improving anticipatory prescribing for end-of-life symptom management. Challenges centred on the introduction of an advanced nursing role into an established medical model. Facilitators included comprehensive record keeping, a collaborative approach and prior specialist experience, as well as peer and management support. These findings may be useful for other areas interested in increasing the effectiveness of palliative INP.
Further audit and analysis of INP prescribing data are needed to confirm these initial findings. This research may then be used to improve prescribing practice as well as inform ongoing palliative service development.
KEY POINTS
- Independent nurse prescribing was introduced to Gibraltar in 2019 and has had a significant impact on palliative care
- Independent nurse prescribing by specialist nurses is well suited to the holistic aims of palliative care
- The two main areas of impact of nurse prescribing in palliative care are facilitating end-of-life care at home and anticipatory prescribing for symptom management at end of life
- Initial challenges were primarily related to the introduction of an advanced nursing role into an existing medical paradigm
- Facilitators included comprehensive record keeping, collaborative working and the support of peers and management
CPD reflective questions
- Do you think that becoming an independent nurse prescriber would enhance your ability to provide palliative care? If so, why? If not, why not?
- From the patients' perspective, what might be the benefits of independent nurse prescribing in palliative care?
- In what ways do you currently navigate professional boundaries in your practice?