Do you allow your nurses to prescribe / diagnose?

RE: Do you allow your nurses to prescribe / diagnose?

Charlotte Marshall — Sun, 28 May 2023 11:03:59 GMT

Just to mention that although it is not on the datasheet for milbemax and other macrocyclic lactones there is a contra indication. If the animal is on ciclosporin there is a risk of increased concentrations in the brain leading to neurological signs. This is in the small animal formulary under contraindications for ciclosporin but not the entries for macrocyclic lactones for some reason.

Though this is stated as a possible risk, it came to my attention after a client started her dog on atopica and it was not noted the dog was on advocate. She reported mild self limiting neurological signs in the first 24 hours after application of the advocate. I have never given macrocyclic lactones to a dog on ciclosporin since.

RE: Do you allow your nurses to prescribe / diagnose?

Evelyn Barbour-Hill — Mon, 22 May 2023 21:13:52 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241584#241584"]

In a number of ways, the vet going into the consult just to confirm bloods are appropriate just undermines the nurse.

[/quote]

I don't see that at all. To put it crudely, RVN says "I think Binky needs a test for hurgleglurge releasing hormone, we must ask a veterinary surgeon" and the VS comes in (as in my opinion, the law requires)and says, "yes, do a test for HGRH please" that actually supports the RVN and certainly builds up her (or his) image in the eyes of the client, as well as showing the client that this is a practice where things are done properly.

No, it sounds as if the OP is seriously worried about getting into disciplinary trouble by working at a practice where things are done illegally or un-professionally.

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241588#241588"]If there is doubt whether a RVN can collect and run bloods in a pu/pd dog then we need to take a long hard look at ourselves and the profession. [/quote]

The doubt is whether she or he can do that without getting the specific approval of a veterinary surgeon.

Perhaps we do need to take a long hard look... but my conclusion at the end might well not be the same as yours.

RE: Do you allow your nurses to prescribe / diagnose?

Michael Woodhouse — Wed, 17 May 2023 19:31:32 GMT

[quote userid="5012" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241587#241587"]

Not sure, and this may stray into veterinary surgeon territory.

If a patient is drinking more, normally one would start by taking a full history and carring out a full clinical examination - then, and only then, would it be decided which investigative tests should be run.

[/quote]

From the RCVS day 1 RVN competencies:

Carry out a nursing assessment ascertaining information about the patient’s normal routine

Guidance
Food and fluid intake; Urination and defecation; Behaviour (response to pain, strangers, commands etc); Mobility; Sleep and rest.
Consider cross-referencing to Section 2.
Perform a clinical examination and record findings

Guidance
To include temperature, pulse, respiration, weight, body condition score and capillary refill times/mucous membranes, non-invasive blood pressure.
Provide husbandry to patients, considering accommodation, nutrition, and excretions

Guidance
Consider age, species, condition, demeanour and enrichment. Calculate food requirements based on disease and life stage/lifestyle, manage assisted feeding to include hand feeding, oral hydration and managing and maintaining feeding tubes.
https://www.rcvs.org.uk/setting-standards/accrediting-primary-qualifications/accrediting-veterinary-nursing-qualifications/rcvs-day-one-competences-skills-and-professional-behaviours-for/part-b-day-one-skills-for-veterinary-nurses-small-animal/

I think the above would gain as much information as any exam I am likely to undertake, and is clearly in the RVN remit

[quote userid="5012" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241587#241587"]Deciding upon and running any blood tests is part of the diagnostic process. [/quote]

Yes, but lets be realistic. We only stock 4 different rotas (comprehensive/prep/T4/electrolytes), so we are not sitting selecting individual tests. IF we accept that nurses can collect pre-op bloods, collect blood and run a pre-mate. The OP has not even clarified if this was a sick animal or even monitoring, pre-op etc. If there is doubt whether a RVN can collect and run bloods in a pu/pd dog then we need to take a long hard look at ourselves and the profession.

RE: Do you allow your nurses to prescribe / diagnose?

Clive Ansell — Wed, 17 May 2023 18:26:13 GMT

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241584#241584"]If an owner comes in for a nurse appointment, for whatever reason, and concerns are raised, I would have no problem a qualified nurse discussing investigation and bloods. I'd have zero problem, for example, a dog coming in for a Librela injection with the nurse, noted drinking more, nurse collect blood and urine and present to the vet. There is no diagnosing going on. Vets available to discuss results.[/quote]

Not sure, and this may stray into veterinary surgeon territory.

Deciding upon and running any blood tests is part of the diagnostic process.

I would be happy for RVN's to carry out routine urinalysis in such a case as above, but beyond that I think they should see a veterinary surgeon.

RE: Do you allow your nurses to prescribe / diagnose?

Nicola Cole — Wed, 17 May 2023 12:50:30 GMT

I read it as: that the nurses were doing blood samples on animals that had never been seen by a vet in the practice? Rather than them attending a nurse clinic as a monitoring thing.

The 2 situations would be very different.

RE: Do you allow your nurses to prescribe / diagnose?

Michael Woodhouse — Tue, 16 May 2023 22:34:40 GMT

[quote userid="10402" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose"]Does anyone have nurses prescribing POM-V flea and worm treatment ( non SQP ) in a generalised way - i.e. not checking with a vet about individual cases and prescribing in their own name ? is this okay in the UK [/quote]

We have a protocol that if an animal has been seen within the last 12 months and weighed recently, then we will dispense Bravecto and Milbemax as ongoing flea and worm prophylaxis. The only contraindication on both data sheets are absolute hypersensitivity reactions, and I've never seen one to either product. I personally don't believe there needs to be a specific note to this effect in the records. Given that qualified nurses are trained in dispensing practice and more than capable of weighing animals, then I am happy that particular dispensing event having no specific vet involvement. Checked by a qualified member of staff if reception or a student.

[quote userid="10402" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose"]Is it okay for a nurse to prescribe POM-V parasiticides if the vet has declined to prescribe it ?[/quote]

No, but why? As I said basically no specific reason not to. I feel a specific 'declined to prescribe' sounds more like a vet pulling rank and undertaking some kind of power play, rather than based on sound clinical reasoning. Can you give the specific example?

[quote userid="10402" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose"]Do you think it's okay for nurses to choose and do blood tests on animals that have not been seen by a vet in the practice or deciding if this is ( ever) and without discussing with a vet ? [/quote]

Again, depends. We offer pre-op bloods (a discussion in itself, for another thread if you so wish), and our nurses do admits. They would take them through the form, know when more likely to be important, and more than capable of answering owner questions if asked. If owner choses yes, then the first I expect to hear about it is when the nurse waves the results under my nose - zero vet input to that point.

If an owner comes in for a nurse appointment, for whatever reason, and concerns are raised, I would have no problem a qualified nurse discussing investigation and bloods. I'd have zero problem, for example, a dog coming in for a Librela injection with the nurse, noted drinking more, nurse collect blood and urine and present to the vet. There is no diagnosing going on. Vets available to discuss results.

In a number of ways, the vet going into the consult just to confirm bloods are appropriate just undermines the nurse. That is what the patient needs, and it's likely the nurses are going to collect and run those bloods. If I'm 'directing' the nurse to do a nurse consult, then I'm 'directing' her to act appropriately within her skill set.

It sounds like the OP has a bit of a problem with nurses?

RE: Do you allow your nurses to prescribe / diagnose?

Sarah Keir — Tue, 16 May 2023 18:38:14 GMT

[quote userid="5012" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241576#241576"]I maintained that there should be a VS in the building, in case of an, albeit very rare I know, adverse reaction.[/quote]

Having seen a vaccination reaction in front of my eyes, I would say that essential that a VS is present in the building.

RE: Do you allow your nurses to prescribe / diagnose?

Sarah Keir — Tue, 16 May 2023 18:36:38 GMT

[quote userid="10402" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241569#241569"]continue working there if become aware of this without falling foul of RCVS / VMD[/quote]

No, you are complicit by allowing it to continue through inaction. Firstly get some evidence so it is not hearsay then go to the top vet in that practice (clinical director or owner), if they aren't interested then take it higher (if corporate) or report to RCVS. Luckily the place I pointed out medicine issues (receptionists handing out repeats without any clinical input, and not flea/worm stuff) the boss eventually decided to take it seriously and act on it but I suspect it was a reason why they made me redundant shortly after.

RE: Do you allow your nurses to prescribe / diagnose?

Clive Ansell — Tue, 16 May 2023 12:19:20 GMT

[quote userid="4181" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241572#241572"]Some of the locums on this forum might also have input on how to handle situations where things are happening that shouldn't be?[/quote]

It happens very rarely; almost all practices I have worked for follow the rules strictly. If anything I think that they interpret them too rigidly and I often feel RVN's or reception staff could do more than they do. An example would be dispensing flea and worm treatments to healthy animals seen within the last year, where a veterinary surgeon has already stated in their notes they are happy to prescribe. Seems a waste of valuable veterinary surgeon time to be dispensing worm tablets.

If I came across a concerning issue, in the first instance I would raise any concerns with the person involved directly, or if unable or unwilling to do that, would speak to someone more senior.

I came across an issue I wasn't happy with about a year ago. RVN's were giving second vaccinations to puppies and kittens that had had their first one with a vet, but sometimes in branch clinics with no VS on premises. I maintained that there should be a VS in the building, in case of an, albeit very rare I know, adverse reaction. Some of the RVN's refuse, but some will do it. I raised my concerns and the practice has now ceased, a VS must be on the premises now.

As ever thought, the guidance from the college is vague, woolly and meaningless. "Nevertheless, it is helpful for a veterinary surgeon to be on the premises at the time the vaccine is administered to the animal, to be able to assist in the event of the animal suffering an adverse reaction"

RE: Do you allow your nurses to prescribe / diagnose?

Rob Loxley — Tue, 16 May 2023 07:16:02 GMT

[quote userid="10402" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/do-you-allow-your-nurses-to-prescribe-diagnose/241569#241569"]can a vet or locum continue working there if become aware of this without falling foul of RCVS / VMD ?[/quote]

https://www.rcvs.org.uk/setting-standards/advice-and-guidance/code-of-professional-conduct-for-veterinary-surgeons/supporting-guidance/whistle-blowing/

https://www.bva.co.uk/resources-support/hr-and-employment/reporting-concerns-and-whistleblowing-for-veterinary-practice-staff-guide

Some of the locums on this forum might also have input on how to handle situations where things are happening that shouldn't be?

RE: Do you allow your nurses to prescribe / diagnose?

Clive Ansell — Mon, 15 May 2023 19:46:45 GMT

Of course not, and assuming the veterinary surgeon as made decent clinical notes stating why they have declined to do so. Prescription only medications can only be prescribed by a veterinary surgeon.

No. Nurses can take blood samples, but a veterinary surgeon would decide what test to run.

It would be Ok for a nurse to take blood and run a total T4 test for example, if a veterinary surgeon had entered in to their notes "see in 6 months for monitoring TT4 test"

It could be, and commonly is, practice policy that POM-V antiparasitics can be prescribed for up to 12 months after an animal has been seen by a VS. If I see an animal for a vaccination for example, I would state in the clinical notes "happy to prescribe F&W treatments up to one year" I know practices where RVN's dispense medications based on veterinary surgeon instruction - "can have repeats of Metacam for up to 6 months" for example

In these cases nurses are dispensing, not prescribing. The veterinary surgeon by saying "can have F&W's for 12 months" is presribing, whereas a nurse following that instruction is dispensing.

RE: Do you allow your nurses to prescribe / diagnose?

An On MRCVS — Mon, 15 May 2023 18:53:53 GMT

okay , can a vet or locum continue working there if become aware of this without falling foul of RCVS / VMD ?

RE: Nurse prescribing / diagnosing

Arlo Guthrie — Mon, 15 May 2023 18:40:45 GMT

[quote userid="10402" url="~/001/veterinary-clinical/small-animal/f/misc-case-discussions/30659/nurse-prescribing-diagnosing"]Does anyone have nurses prescribing POM-V flea and worm treatment ( non SQP ) in a generalised way [/quote]

That would be against the "lower", as Inspector Clouseau used to say, making it somewhat foolhardy for anyone to answer the question with a 'Yes'!

https://www.bva.co.uk/take-action/our-policies/veterinary-nurse-prescribers/