The Change from Practice Nurse to Nurse Prescriber

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I have worked as a Practice Nurse since 2001 and at Students’ Health Service (SHS) since 2003, completing various courses over these years – minor illness/injury, contraception, sexual health and travel health. As a result of this experience and knowledge, I felt the next step was to be able to prescribe for certain conditions that I felt competent in; to complete episodes of care and to help reduce the number of doctors’ appointments within these specialities at SHS.

Therefore in 2011 I qualified as an Independent Nurse Prescriber, which involved undertaking a recognised Nursing and Midwifery Council (NMC) accredited prescribing course through a UK university.

Legislation to allow nurses to prescribe from an initially restricted list was introduced in 1986, and gradually nurses were given more autonomy, eventually culminating in Nurse Prescribers having full access to the British National Formulary (BNF) which has put nurses on a par with doctors in relation to prescribing capabilities. Although we have access to the BNF, this does not mean we can prescribe everything in there – we only prescribe within our own limitations and scope of competence. So, for example, I feel competent to prescribe antibiotics for certain conditions, and contraception methods, but I do not feel competent to prescribe anti depressants or diabetic medications.

Before the Change – Scenarios I would see in Practice…

“I feel REALLY terrible… I can hardly swallow as my throat is so sore, I can’t seem to get warm, but feeling freezing cold and sweating and I have painful swellings around my neck. I’ve come to Student Health and after waiting to see the nurse and having been assessed, I have been diagnosed with Tonsillitis. I’ve been given a leaflet with information about medicines I should take from the pharmacy to help with my symptoms, but I need to see the doctor for a prescription for antibiotics. I have to sit and wait now for my appointment. The waiting room is full, too much noise and I just want to go home and back to bed…”

“Oh… the nurse is running late… I’ve a lecture in 15 minutes. I just want to start the pill. My friends are all taking it and now I’m with Tom, I don’t want to repeat that episode with the split condom and having to take the emergency pill last month- how stressful was that… Hooray! I’ve been called in… after a few checks and lots of questions looks like I’m ok to take the pill- but the nurse cannot prescribe it and I now need to see a doctor… I’ll have to book an appointment on another day for my prescription as I need to go to my lecture…”

 

After the Change…

Advantages for me as a Practitioner

Being a Nurse Prescriber has increased my autonomy and independence at work leading to greater job satisfaction, especially in my specialised field of travel health medicine, which here at Students’ Health is now entirely nurse-led.This independence provides more streamlined care that is patient-focused.

Advantages for you as a Patient

Continuity of care, with particular reference to the scenarios as above – these are consultations I see fairly frequently and can complete independently in one appointment without the need for referral to a doctor for a prescription. This ensures timely access to medicines and treatments, increasing convenience for you.

Advantages for Students’ Health

Nurses being able to prescribe at SHS increases service efficiency by freeing up our doctors’ time to care for patients with more complex health care needs. We have three Nurse Prescribers at SHS.

Advantages for Secondary Care (Hospitals)

Evidence has shown that Nurse Prescribing helps to avoid unnecessary A&E and hospital admissions and improves access to treatment.

So please, when booking your appointments at SHS, check to see if a Nurse Prescriber can help you with your health care need – we are here to help you.

Students With Children!

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Combining studying at University with raising a family can be a challenge but we are here to help. We recognise that not all students are the same. Whilst we offer a specialised Students’ Health Service tailored to the needs of our patients, we are also an NHS general practice. As such we provide services that student parents may be interested in. This includes antenatal and postnatal care for mothers. Then after the baby is delivered we offer the full range of child health checks and recommended immunisations.

 When necessary we also provide travel advice and immunisations for children as well as adults. We work closely with our Health Visitors to support families. Within the university there is now even a coffee morning run by the UBU. It takes place every Thursday during term time 9.30-11am. Students can go along to meet other parents and bring their children. Click on the link to find out more;

www.ubu.org.uk/studentparents

The Olympic Games and the Untold Legacy

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This blog is a personal viewpoint from the service’s eating disorders specialist…

Will Devlin, clinical psychologist and specialist in eating disorders for the University of Bristol, looks almost sheepish as he describes his mixed feelings about the great sporting achievements we watched with pride just a few months ago:

“…Don’t get me wrong,” he says, “there’s no doubt that the Olympic Games were a proud moment in the history of the country and many of us have been inspired by the achievements of athletes like Jessica Ennis, Jonnie Peacock, and Anthony Joshua.

“But what I can’t help wondering is what effect images of these almost superhuman, super lean, super muscled athletes is having on people who are unhappy with their bodies.  Very few of us have the genetic make up, let alone the motivation, dedication, sponsorship, training and time to develop the kind of body which we’ve seen so much of during the UK’s summer of sport.

“It’s one thing to be inspired to get fit by the Olympics, even I’ve been inspired to get back to the gym.  But the fact is,” Will says with a smile, patting his tummy, “like most of the population I’ll never have the body of an Olympian however hard I try! 

His fear is that amidst the pride and positive social change inspired by the Olympics, one untold legacy will be an increase in the number of people at risk of eating disorders: “I worry that if more of us end up unhappy with our bodies, then more of us might resort to unhealthy attempts to shape up as we aspire to a rippling six-pack, tight buns or super-pert breasts.

It’s not a popular view, that inspiring a nation with acts of sporting heroism could actually be bad for some people, but as I listen to Will’s concerns I do see his point: “Condemnation is growing on all sides at the use of size zero models on the catwalk, and Kate Moss was roundly criticized for endorsing starvation when she said, ‘nothing tastes as good as skinny feels’ …but it’s not easy to say that super lean athletes might have just the same effect as emaciated supermodels on those of us who want the perfect body but simply can’t have it.  “And don’t forget,” Will says, “the athletes themselves face these same pressures, eating disorders are rife amongst sports men and women, in fact it is estimated that more than one in 10 elite athletes may have an eating disorder.”

Will’s comments get me thinking about this untold legacy, and what some of the unintended outcomes of our summer of sport might be.  There’s no doubt that the efforts of Team GB and our paralympian heroes have the power to inspire a generation, but perhaps it’s also important to recognize that the pursuit of athletic success and the body beautiful may also have its downsides.

Will works at the University’s Student Health Service.  If you think you might have an eating disorder, talking to one of the service’s GPs will ensure you get access to the specialist help you need.

 

Reflections on Body Image

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Last month the Students’ Health Service had a visit from our local MP Stephen Williams, a member of the All Party Parliamentary Group on Body Image. He was interested to hear about our work with students with eating disorders, but we also talked through the challenges of being a student with a condition such as Body Dysmorphic Disorder, and the misuse of body building drugs such as anabolic steroids in some parts of our population.

Negative body image underlies much of the mental health work we do, whether it leads to low self esteem (which can itself lead to depression or self harm), anxiety, social phobia, and more obviously anorexia and bulimia.

The report highlights more positive ways to view ourselves and our bodies, such as the Health At Every Size movement, which focuses on health rather than weight/ Body Mass Index. This movement tries to encourage us to eat healthily and engage in appropriate amounts of physical activity and has been shown to lead to higher levels of self esteem, and better blood pressure and cholesterol levels.

Anecdotally the medical community is certainly becoming increasingly wary of using BMI as a ‘one size fits all’ measure, as we watch the generations increase in height and muscle mass. Even traditional children’s measurement charts have had doubt thrown over them, with a current study from the University of Worcester identifying healthy children as being incorrectly labelled ‘obese or overweight’ by the National Child Measurement Programme. This could then lead to those children developing neuroses about their height and weight in the future, in our ‘weight obsessed society’.

Fixating on a particular weight may not be the best approach for us, and it might be better to take a more holistic approach  with better health being the best outcome measure to aim for; focus on Fitness rather than Fatness, if you like.

If you are worried about your weight/ shape or health, then please do come and see us to talk it through. We are very used to discussing these issues, and I hope you will find us good at listening and keen to help.

 

http://issuu.com/bodyimage/docs/reflections_on_body_image

 

 

Self Hypnosis; what could you do?

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Self-hypnosis: what is it that you want?

by Matt Edwards; Sports, Exercise and Health Dept

Imagine or remember this. Sat in the library or at a desk, reading up for next week’s essay. Get to the end of the page, and realise….you’ve not taken in a single word. In fact it’s like you’ve just woken up, drifted back to reality. Where have you been?

One way to think about this is as follows;- it happens sometimes when you’re driving (“how did I get here?!”) –  it’s a kind of light ‘trance state’, a zoning-out, where your mind and body can do quite complex things like reading or driving, but – and this is the good bit – you’re doing this stuff quite happily whilst an important part of you is thinking about something else entirely.

Sometimes called day-dreaming, it’s a natural and useful experience, even a skill, that too often we’re told not to engage in.

You can learn to deliberately use and enhance this skill through self-hypnosis. Self hypnosis is a powerful, congruent way to go into and explore these kinds of natural, resourceful states of mind. Whether for simple relaxation, or as a chance to allow your mind to examine an idea or a goal or an issue, the change in mind-body state that self-hypnosis encourages can be enormously powerful.

Imagine being able to have better control over your state of mind, to decide how confident you want to feel going into your PhD viva, as one recent student I worked with discovered for herself.

How good could that be? And what is it that you want?

Eating Your Heart Out

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Many of us eat chocolate when we want a treat, or when we’re having a bad day – and where’s the harm in that? 

 

We don’t just eat for health; the fact is eating is one of life’s pleasures.  There’s no reason why we shouldn’t enjoy food or use it now and then to lift our spirits: as the saying goes, “all things in moderation.” The difficulty comes when comfort eating becomes our main way of dealing with upset. 

 

Comfort eating provides a distraction from difficult thoughts and negative emotions but when it’s our only way of coping it can easily get out of hand: a bar of chocolate or a slice of toast can be the trigger for a full on binge.  Many people who overeat like this say that whilst they’re bingeing everything else seems to stop: they feel in a world of their own where difficult thoughts and feelings can’t touch them.  It’s only afterwards that the distress returns, only when it does it’s made worse by uncomfortable bloating, concerns about weight gain, frustration, guilt and shame. 

 

Such negative feelings in the aftermath of a binge can erode self esteem and increase vulnerability to future stresses and from here it’s easy to see how a vicious cycle can develop: upset leading to binge eating and binge eating leading to greater vulnerability to future upset so making binge eating ever more likely.  Many specialists see such vicious cycles as being at the heart of eating disorders.

 

There’s no harm in eating for comfort now and then, but if you find yourself trapped in the vicious cycle then it can be useful to know that there are ways of breaking out.  Whilst many people can break out on their own and with the support of friends and family, some people will need professional help. 

 

If you are struggling to manage disordered eating then perhaps the Student’s Health Service can help.  The Service offers specialist support for people with eating disorders and many students have used it to turn their lives around.  If you think you might need specialist help then the first step is a visit to your doctor.  Whilst it can be embarrassing to talk about such problems, all our doctors are fully trained and highly experienced in working with people battling eating disorders.   they may refer you to the practice’s psychologist or on to a more specialised doctor. There’s no shame in seeking help: rest assured you’ll be treated in confidence, with respect and sensitivity.

www.b-eat.co.uk

 

 

Club Drugs; help is at hand!

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My name is Dr Tim Williams and with my colleague Elaine Driver we run Bristol’s ‘Club Drug Clinic’. This is only the second such clinic nationally and is a response to changing trends of drug use in young people.

In the last 10 years there has been a steady reduction in young people using drugs such as cannabis, ecstasy, cocaine, and heroin. Increasingly young people are buying compounds directly from internet sites for delivery. More and more young people are now finding they have developed a problem with internet substances and need some help and support. Others are wanting accurate information to ensure they are not using toxic substances. Since the media storm around mephedrone there has been a diversification in the market and new compounds emerging, usually from labs inChina, in rapid succession. Some of these compounds have been harmless but others have been poorly researched and trialled, resulting in psychoactive chemicals which are highly potent and have a very narrow safety window. Consequently in Bristol we have had several young people die after taking white powders that the press erroneously labelled as MDMA or ecstasy. The Club Drug Clinic aims to provide up to date information and advice to people who are using well known compounds such as ketamine, methoxetamine, and methiopropamine or branded internet compounds such as BenzoFury or NRG.

I am part of Professor David Nutts’ Independent Scientific Committee on Drugs (ISCD). The ISCD draws together experts in the field of drug science and allows us to have the most up-to-date information on what is out there. The forensic scientists on the committee have amazing knowledge and experience of analysing and characterising new compounds that come onto the market. Part of my role in the Club Drug Clinic is to get any information from users about compounds that have caused problems or side effects, so we are always interested in hearing about your experiences. Anyone can come in and talk to us anonymously for a chat and to share information.

If someone needed more help and treatment we would start seeing people regularly and could link into our extensive treatment services which includes detox if this was necessary.

 We are open for drop-in every Wednesday between 5-7pm at Colston Fort, Montague Place, Kinsdown, BS6 5UB. Its just off St Michaels Hill, just ring the buzzer and we would love to meet you.

Antidepressants; friend or foe?

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Antidepressants; friend or foe

 Two (unrelated) students asked me to write this blog. Independently they mentioned at the end of their consultations that there was a lack of positive stories about using antidepressant medication, and that other students might like to hear about some success stories such as theirs. They felt that these ‘good news’ tales might balance some of the very negative opinions that they and their peers were reading online.

Well I have worked at the Students’ Health Service for over 10 years and it has certainly been my experience that the vast majority of students that I treat with antidepressants get better. Treatment times vary, as does the need to try more than one type of pill before finding that one that works for an individual, but alongside psychological therapies, medication is usually successful in helping students return to normality.

Of course we must consider possible side effects (minimised by starting with a half dose for the first week in many cases), and appropriate length of treatment (6 months for a first episode, 2 years or more for recurrences ). It is also vital to withdraw the medication very slowly tailored to an individual’s response. The GPs at SHS are fastidious in planning regular follow up for patients on antidepressants and strive to have continuity of care to allow us to get to know each student as best we can, therefore giving a better overview of treatment response.

Evidence suggests that medication is most appropriate in cases of moderate to severe depression, so we are much less likely to prescribe it for mild cases, and we always encourage other supportive treatments such as increased exercise, counselling and psychological input as necessary.

Six million people are thought to suffer from depression in the UK, and in the last few years the NHS has noted a significant (26%) rise in the prescription of antidepressant medication. Much has been written and theorised on the reasons for this, but it is a phenomenon noted throughout the population, and students are no exception unfortunately. In the face of rising numbers of people with mental health issues it is good to have a treatment that works to offer them, and which shows benefit within usually 4 to 6 weeks. Sometimes people need to take something just to be able to get back to a point of functioning well enough to start talking therapies, of which there is steadily increasing availability on the NHS.

Antidepressants work for the majority of students that we treat, though it needs to be the right one for the individual. They can be life changing, and should always be considered and discussed as an option, though decisions should be made on a case by case basis of course.

I am confident in stating that antidepressants are an important option to be considered in the consultation between the GP and any student who is feeling depressed, and we see significant positive effects on an almost daily basis in our population. It is true that these good news stories don’t excite the media in the same way as negative stories, but that’s no great surprise.

If you are worried about your moods, or feeling low, please do come and talk to us, we really do want to know and help you, in whatever way suits you best.

 

“Home is the nicest word there is”

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Homesickness

 

Home is a place you grow up wanting to leave, and grow old wanting to get back to.  ~John Ed Pearce, American Newspaper Editor/ political speech writer

Freshers’ week is over, the excitement has been countered by your course reading list, and reality is starting to have an impact…

New surroundings, new people, new accommodation, and in many cases a new climate, sometimes all in a new language! Home can seem a very long way away. For some people feeling homesick will briefly impact on their consciousness and then they’re off again, whirling through Bristol, eyes on their next challenge. For many people however, overcoming the homesickness IS the challenge.

Maybe this is a good time to reflect on the fact that with about 4000 new people all joining the university in the same week, those who feel homesick are unlikely to be alone in feeling this way. Certainly from where we sit, here at the Students’ Health Service, and in the experience of our colleagues in Student Counselling, and the Multifaith Chaplaincy, we know you are not alone in wishing that your nearest and dearest, and the comforts of home, were a little closer. We recognise how common an emotion this is and therefore we are here to help you deal with it and move onwards to enjoying your time at Bristol as much as you can. The Counselling Service run all sorts of groups and workshops throughout the academic year, with some specifically aimed at supporting people who are homesick. Look at their website for more information, and to book a place on them. And don’t forget that the Chaplaincy is for people of any faith AND none. You wont find a friendlier team providing soup lunches and support anywhere in the university!

My message for this blog is that you are not alone, and that we are all here at the Student Support Services ready to help and listen. It is better to seek advice early than to struggle on alone, we can help.

 A final thought on leaving home;

 “Maybe you had to leave in order to really miss a place; maybe you had to travel to figure out how beloved your starting point was.”
― Jodi Picoult, author Handle With Care

 

http://www.bristol.ac.uk/chaplaincy/

 http://www.bristol.ac.uk/student-counselling/

 http://www.bristol.ac.uk/students-health/

 

Contraception; your options!

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Dear students, and in particular those new to the university and Bristol.

Welcome! You have picked a great city and it’s an exciting time for you all. Parties, Fresher’s week, new friends, often your first time away from home and a new course to get stuck into.

First let me introduce myself. I am Dr Tim Percival; lead GP for contraception at the Students’ Health Service (SHS). I felt it was a good time to get the message out to you all regarding your choices, what we can offer and trying to correct some of the common misconceptions regarding contraception.

We have comprehensive facilities to manage the vast majority of all contraception and sexual health issues from:-

  • Choosing the right contraception and sorting subsequent problems
  • Diagnosis and treatment of sexually transmitted infections (STI’s)
  • Taking cervical smears (if over 25 years)
  • Providing condoms and pregnancy tests free of charge
  • Generally helping you with any symptoms and problems ‘down below’.

We pride ourselves on being approachable and friendly, and we take confidentiality very seriously. So please just come and talk to us!

It is commonly thought that the contraceptive pill and condoms are the ‘usual and only’ options.Condoms are good protection from STIs and are a relatively safe method of contraception but ONLY IF USED CONSISTENTLY AND CORRECTLY.

The pill is a very good option too, especially for those that like good control of their periods. It is a misconception that the pill makes everyone put on weight and become very ‘hormonal’…this is unusual. It is also not a problem to continue the pill long term if you’re fit and healthy.

Longer Acting Reversible Contraceptives (or LARC’s) are becoming very popular for good reason. They give you the benefit of highly reliable contraception that is not prone to ‘user failure’ i.e. ‘had a few heavy nights and forgot my pill’! They are also statistically better at preventing pregnancy. The options are:-

  • Contraceptive implant called nexplanon,
  • Contraceptive injection or depo
  • Intrauterine devices i.e. the copper or hormone coils.

Let’s take each of these in turn and try and dispel some common misconceptions!

 Implant

  • Injected into inner upper arm where can’t be seen and releases hormone slowly
  • Lasts 3 years
  • Generally a simple insertion and removal with at most mild pain from small anaesthetic injection similar to vaccination
  • Very highly effective
  • Low risk hormonal side effects

 Injection/Depo

  • Injected invisibly into upper buttock and hormone released slowly
  • Lasts 3 months
  • Mild pain from injection similar to vaccination
  • Very highly effective

 Coils

  • 2 types 1) copper (IUD) and 2) Mirena (Hormone IUS).
  • Copper IUD lasts 10 years, has no hormones but can make periods slightly heavier so good for any of you with lighter periods
  • Mirena IUS lasts 5 years, has very small amounts of hormone that works locally in the womb to lighten periods so good for those with heavier periods
  • Both very highly effective
  • Can be fitted even if not had children!
  • Can be fitted at Students’ Health
  • Do not make you infertile in the long term (only when device in place!!)
  • Usually mild-moderate period like cramps during fitting. Usually not significant pain during insertion as commonly believed

 

Please remember that none of the above methods protect you against STIs so make sure you also use a condom unless:-

  • with a regular partner,
  • AND you have both had comprehensive STI screening
  • AND you are using an alternative contraceptive method e.g. pill/coil/implant etc.

 If you do have unprotected sex then please see us ASAP for emergency contraception. If we are not open chemists, A+E departments and sexual health clinics can also supply this for you. If you do get pregnant and don’t want to be please try not to panic and see us for advice on your options.

Hope this is helpful. Look forward to meeting some of you. EnjoyBristol!

Dr Tim Percival

GP Students’ Health Service