Mapping the Road Travelled

1
Mapping the Road Travelled Project Team
Kathleen Walsh Denise Carroll
2001
2005
2
Background to the Review

• Commission on Nursing 1998
• (Government of Ireland)
• Scope of Practice for Nursing and Midwifery
  2000 (An Bord Altranais)
• Nurses and midwives expressed difficulty
• with meeting the needs of patients and clients
• for medication management.

3
The Review Structure
Nursing, Midwifery, Medicine, Pharmacy, DOHC,
Patient Representation, Health Service
Management, Educationalists
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Terms of Reference

• 1. Review of current practice, identifying
  relevant issues
• 2. Review of appropriate international literature
  experience
• 3. Review of national international legislation
  relating to nurse midwife prescribing
• 4. Review of Guidance to Nurses and Midwives on
  the Administration of Medical Preparations (An
  Bord Altranais, 2000)
• 5. Review of intra- inter- professional issues
  their implications for nurse midwife
  prescribing

5
Terms of Reference

• 6. Consideration of the circumstances in which
  nurses and midwives might prescribe
• 7. Identification of pilot sites suitable for the
  initiation of nurse and midwife prescribing
• 8. Identification and delivery of educational
  preparation necessary to support nurse and
  midwife prescribing
• 9. Consideration of documentation necessary to
  support nurse and midwife prescribing
• 10. Initiation and evaluation of nurse and
  midwife prescribing in pilot sites
• 11. Production of detailed guidelines including a
  framework for nurse and midwife prescribing where
  appropriate

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Review Structure 2001 - 2005

• Progressive Literature Review
• Medication Management
• The Prescribing Process
• Prescribing Practices
• International Experiences Outcome Studies
• UK, USA, Canada,
• New Zealand, Australia, Sweden

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What are the Prescribing Models?

• Independent
• the nurse/midwife is authorised to
• independently prescribe or advise about
• medications. A limited or open drug formulary
• may be used to determine the specific
• medication to be prescribed, as per legislation
• and local policy.

Doctor not required to be involved
full accountability responsibility
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A different approach with

• Collaborative prescribing
• the nurse/midwife is authorised to prescribe
  medicine in collaboration with a medical
  practitioner. Written practice agreements or
  verbal consultations may be necessary
• Direct on site supervision not always required
• Some situations doctor needs to sign the
  prescription
• Model has many variations - internationally

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Medication Protocols
Not strictly prescribing
Authorisation of the nurse/midwife to initiate,
administer or supply a medication to groups of
patients in a defined situation Use of written
guidelines developed by healthcare team for nurse
to give a specific medication for a specific
indication or health condition Aspirin to treat
chest pain, Vitamin K for newborns
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Main outcomes associated with nurse prescribing
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Research studies

• Mixed research methodologies
• Studies mainly from US UK
• Majority in primary care setting

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Appropriate safe prescribing

• Burlington Trial (Spitzer et al. 1974) first
  study to examine nurse prescribing in primary
  care setting
• RCT of 817 patients
• Prescribing of 13 common drugs by Physicians
  
• Nurse Practitioners
• In 510 prescriptions analysed, an adequate
  rating
• was given to 75 in the Physician group and to
  
• 71 in the NP group

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• More recently, Mayes (1996) studied the
  prescribing patterns of 41 NPs, primarily working
  in general practice (US)
• Results showed that the NP did not veer outside
  her
• scope in regards to meds prescribed, which
  reflected
• their expertise, education qualifications and
  patient caseload
• Safety of nurse prescribing is also supported in
  other studies (Cox Jones, 2000 Myers et al.
  1997 Rosenaur et al. 1984)

14

• Cox, Walton and Bowman (1995) compared the
  prescribing decisions of nurses SHOs to
  consultant dermatologists in a hospital setting
  (UK).
• 48 patients admitted for treatment of
• eczema/dermatitis or psoriasis included in the
  trial
• Number of differences between nurse consultant
  
• was less than that of the SHO (20/100 v 39/100)

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Patient Satisfaction

• Why is it important?
• Age of consumerism
• Nurse prescribing - Blurring of traditional
  boundaries?
• New service must be at least as good if not
  better as existing one

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• Shum et al (2000) RCT of 5 GP practices (UK)
• To assess the acceptability effectiveness of
  a minor
• illness service led by practice nurses
• 1815 patients assigned to treatment by nurse
  or GP
• Results showed that pts were significantly
  more
• satisfied with the nurse consultations than
  those given
• by GPs
• Similar results found in both UK and US
  (Kinnersley
• et al. 2000 Myers, 1997 Horrocks, 2002)

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Lessons learned?

• While patient satisfaction is prevalent in the
  studies examined above, some contention has been
  noted
• Brooks (2001) found some patients in a general
  practice had reservations regarding the
  educational preparation for nurse prescribing in
  the UK
• Education programme since extended

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Time savings easier access

• Touche Ross (1991) interviewed medical, nursing
  pharmacy staff in community
• Luker (1997) 1st major evaluation of nurse Rx in
  UK
• Results - main benefits were time saving
  convenience
• Other studies substantiate these findings
  (Brooks, 2001 Tallet Brooke, 1992 Biester
  Collins, 1991)

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More information provided

• The communication skill of the nurse in the
  care of the patient has been found to play a
  crucial role in making the case for nurse
  prescribing (Jorm, 2000).
• Qualitative study of 50 patients in one primary
  care group explored nurse prescribing from pts
  perspective (Brooks, 2001)
• Results pts lauded nurses ability to Rx owing
  to continuity, approachability provision of
  information
• Nurses style in providing information (Luker,
  1997)
• Also supported in AE (Cooper et al. 2002 Byrne
  et al. 2000) Mental Health (Nolan et al. 2001)

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Improved patient compliance with medication

• Patient outcomes of NPs were compared with
  physicians in primary care (Brown Grimes, 1995)
• Compliance taking meds, keeping appointments
  following advice on behavioural changes
• Results showed better compliance by pts seen by
  NP
• Findings supported (Nolan et al. 2001 Jorm 2000
  Office of Technology Assessment, 1986)

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Less pharmacological interventions

• Mahoney (1994) compared NPs to physicians in
  primary care to determine if extending
  prescriptive authority to NPs reduced the quality
  of prescribing
• Results - physicians mean score on
  appropriateness was 13.3 compared to NPs score
  of 15.3
• NPs found to Rx less drugs more non-drug
  treatments than medical colleagues (NPs 1.7 v 2.7
  Physicians)
• Findings supported elsewhere (Avorn, 1991 Munroe
  et al. 1992 Simborg, 1978)

22
Appropriate clinical decision-making

• Survey of primary care Physicians NPs to assess
  their clinical decision making (Avorn, 1991)
• Each participant presented with a case vignette
  
• describing a patient with epigastric pain,
  with a
• report showing diffuse gastritis
• Results showed more than 1/3 physicians chose
  to
• begin treatment without seeking a relevant
  history
• in contrast to only 19 of NPs
• NPs asked more questions
• NPs far more likely to choose non-drug approach
• Drugs prescribed less by NPs 20 v 63

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Cost effectiveness

• Venning et al (2000) compared the cost
  effectiveness of
• GPs NPs in primary care
• 1300 pts assigned to GP or NP in 20 GP
  practices
• Outcome measures included consultation process,
  
• pt satisfaction cost
• Results showed that nurse prescribing did not
• increase costs
• No evidence to suggest nurse prescribing would
  cost more than that of their medical colleagues
  (Ferguson et al. 1998 Touche Ross, 1991 Munroe
  et al. 1982)

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Main outcomes associated with nurse prescribing

• Appropriate safe prescribing
• Patient satisfaction
• Time saving, easier access
• More information provided

• Improved patient compliance
• Less pharmacological interventions
• Appropriate clinical decision making
• Cost effectiveness

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Project Activities
Guidance to Nurses Midwives on Medication
Management
Medication Management Seminars
Query Database for Medication Management
Needs Assessment Survey
Exploration of Need Survey
Pilot Sites for Collaborative Prescribing
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Medication Management Seminars
Position or Title of Attendees
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Medication Management Seminars
Practice Area of Attendees
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Focus Group Objectives

• To learn about their present practices of
  medication management and thereby identify any
  areas that might need to be addressed in future
  revisions of the guidance document on medication
  management.
• To invite participants to share practices and
  activities that have improved medication
  management in their settings and/or could be
  employed to do so.
• To explore the need for nurses and midwives to
  prescribe

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Focus Group Perceptions

• Benefits of prescribing
• More timely treatment
• Legal clarification
• Safer patient care
• Influence of nursing
• Professional development
• Cost-effectiveness

• Rationale for introducing prescribing
• Interest of patients
• Time delays
• Present practices
• Medical manpower issues

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Focus Group Perceptions

• Models of prescribing
• Collaborative model preferred
• Initiating OTC medications for patients seen as
  greatest need

• Essential elements
• Education various viewpoints
• Legislation - to clarify current practices
• Wanted experience recognised in considering who
  should prescribe
• Support resources needed to be in place for all
  aspects of medication management

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Professional Guidance

• Focus on
• Scope of Practice
• Interdisciplinary nature of medication management
• Competency of practitioner

Revisions founded upon Professional concerns,
expanding practices of profession, findings of
medication management seminars
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Needs Assessment Survey

• Research Objectives
• 1. To identify which models are needed by nurses
  midwives
• 2. To identify the practice settings in which the
  prescribing models are needed
• 3. To ascertain why nurses midwives need
  particular prescribing models

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Research Objectives

• 4. To identify what resources nurses midwives
  would need for implementation of the prescribing
  models
• 5. To consider what nurses midwives perceive to
  be the benefits of each prescribing model.
• 6. To outline the reasons why nurses midwives
  do not want to prescribe independently or
  collaboratively
• 7. To identify which medications those who chose
  the independent/collaborative models might need
  to prescribe.

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Sample Size Divisional Breakdown
35 response rate generally comparable across
divisions
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Profile of Survey Respondents

• Gender 898 were female (94) 60 were male
• Age Highest numbers were in the 40-49 age group
• Additional post-registration academic
  qualification
• Certificate was achieved by the largest group of
  respondents (n361) 17 had achieved a higher
  diploma, 16 had a degree.
• Place of work Majority worked in hospital 57
  in a urban setting with 34 working in the
  Eastern region
• Current practice area Care of the older person
  setting or a medical/surgical ward (18 for each)
• Current position held Staff Nurse or Midwife
  (55 of respondents) 54 were in their current
  position between 1 5 years. 46 stated they
  were in a nurse-led unit

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Survey Results Direct Care Providers
Which prescribing practices are needed by nurses
midwives?

Collaborative Model 48 Protocol
Use 31 Independent 14 No Model Required 7
37
Model selected influenced by
Highest post-registration Academic qualification
Current position
Working in a collaborative environment
Geographical Area
Practice setting
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What model and where?

• Independent model most favoured by those
  working in midwifery public health
• Protocol model greatest support from those in a
  medical/surgical setting
• Those practising in psychiatric settings were
  most likely to say they did not need to prescribe
  regardless of the model

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Which medications would you need to prescribe?
40
Exploration of Need Survey
Views sought from doctors, pharmacists, patient
groups, professional bodies about The need for
prescribing by nurses midwives Benefits (if
any) of prescriptive authority Assurance of
quality safety to patients
41
Survey Structure

• Description of prescribing practices of nurses
  midwives internationally
• Six case scenarios of current practice situations
  in the Irish health care system
• Eight open-ended questions

42
Survey Findings Centred on

• Support for the prescribing models
• Patient benefits
• Practice settings where it should be introduced
• Benefits to the nurse/midwife
• Necessary elements for its introduction
• Promoting the efficiency of healthcare delivery
• Acceptance by patients

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What were their views?
Patient Benefits

• Support for prescribing
• 17 out of 20 supported its introduction
• Collaborative model most favoured greatest
  impact for service

Suggested Practice Settings
Primary care, AE, hospice, acute care
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Benefits to the Profession
45

Necessary elements for its introduction
Efficiencies in delivering care

• Fewer hospital admissions
• Quicker discharges from hospitals clinics
• Potential in GP visits
• Solution to European Working Time Directive
  doctor unavailability
• Allocation of healthcare staff to sicker patients
• Cost-savings coming from less dependency on
  services
• Quality of care improved

• Legislation professional regulation
• Education
• Professional accountability liability
• Policy protocol development
• Inter-professional support collaboration
• Resource allocation

Acceptance by patients generally yes, need
to consult and educate, questions of role
confusion access to choice
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Pilot Study

• Research Design
• The model of collaborative prescribing involved
  the supply and administration of medications by
  the participating nurses and midwives using
  locally devised protocols.
• Supporting Structures
• Project plan
• Medication protocol framework
• Competencies for collaborative prescribing
• Education programme

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How were the sites chosen?

• Criteria for Nurse/Midwife Participation
• On the active Register of An Bord Altranais
• Minimum of three years post-reg clinical
  experience
• One-years experience within the specific area of
  practice
• Evidence of continuing professional development
  gt5 days/2 years
• Successful completion of the education programme

• Selection Process
• Regional and geographic diversity
• Identification of service need
• The professional need for prescribing by the
  nurse/midwife
• Scope of practice diversity
• Existence of collaborative relationships amongst
  the health care staff
• Named doctor(s) pharmacists

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Initial Pilot Sites

• Inismaan Community Services Public Health
• St Jamess Hospital Sexual Health
• National Maternity Hospital Domino scheme
• St Lukes Hospital Oncology
• Rotunda Hospital Neonatal ICU
• Limerick Regional Hospital Coronary Care
• St Marys Hospital Intellectual Disability
• St Patricks Hospital Care of the Elderly

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Initial Pilot Sites

• Clondalkin Mental Health Services Psychiatry
  
• Midland Regional Hospital Heart
  Failure Clinic
• Virginia Primary Care Team Primary Care
• Waterford Regional Hospital A E
• Lifford Health Centre Primary Care
• Sligo General Hospital Midwifery
• St Finbarrs Hospital Care of the Elderly

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RCSI Education Programme
Units of study Professional, ethical legal
practice Diagnosis/systematic assessment
evaluation in patient care Pharmacology
prescribing Communication, collaboration
inter-professional relationships

• Provided over 6 months, combined classroom
  instruction w/ clinical mentorship with a
  designated medical practitioner
• Competency framework for collaborative
  prescribing
• Student Assessment
• Objective Structured Long Examination Record
  (OSLER)
• Written assessment
• Presentation of an individual medication protocol
• Achievement of competencies sign off by mentor

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Implementation Evaluation PhaseNovember
March 2005

• St James Hospital
• National Maternity Hospital
• St Luke Hospital
• Rotunda Hospital
• Limerick Regional Hospital
• Inismaan Community Services
• St Marys Hospital
• St Finbarrs Hospital
• St Patricks Hospital

• Measurement Tools
• Clinical Decision-Making Audit Tool
• Patient Satisfaction with Information on
  Medicines Tool
• Post-Evaluation Questionnaire

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Results Audit Tool

• Positive
• Clinical decision-making appropriate
• "Accurate documentation, high quality
  professional work.
• "Good evaluation of patients needs prior to
  treatment and alternatives explored."
• Improvements Adverse event reporting

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Patient Satisfaction with Information on
Medicines

• Majority of patients treated were completely
  satisfied with the information provided by the
  nurse/midwife participant
• Limited findings interpretation due to
• Diversity of practice settings
• Anonymity of sites

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Post-Evaluation
Easier access to treatment Provision of holistic
care More timely treatment

• Patient Benefits
• Health Service Provider Benefits
• Better use of Healthcare Team
  Resources
• Greater Use of Professional Skills of nurses
  midwives
• Collaboration generally worked well in sites
• Education Programme - majority satisfied that it
  meet their needs, competency framework beneficial
• Structure and Process of the Model did it work?
• Yes especially out of hours after 5pm,
• Some found it restrictive due to limitations of
  model,
• protocol development time consuming

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Post-Evaluation

• Comment by participating doctor
• "In general, the nurses prescribing powers
  (limited) were welcomed by other
  multidisciplinary team members...Perhaps
• giving limited prescribing powers to all nurses
  (who receive appropriate education) would lead to
  better medication management and patient care."

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Mapping the Road Travelled

• Examination of the various influences on expanded
  medication management practices
• International experiences
• Outcome studies
• Developments in Ireland
• Professional guidance

• Review activities
• Medication management seminars
• Needs assessment survey
• Exploration of need survey
• Revision of guidance document
• Pilot study

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• Recommendations of the Review

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Recommendation 1 Continuation of the Use of
Medication Protocols

• The use of medication protocols (other than for
  controlled drugs under the Misuse of Drugs Acts)
  within hospitals is recognised by the Department
  of Health and Children as an established practice
  of medication management. The use of such
  protocols should continue to be developed and
  supported.

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Action 1.1 Professional Guidance

• An Bord Altranais will revise the current
  Guidance to Nurses and Midwives on Medication
  Management to incorporate the medication protocol
  framework used in the Review.
• Action 1.2 Health Service Provider
  Responsibility
• Provision should be made by health service
  providers for the development and implementation
  of medication protocols in hospitals.

60
Provisions should be made

• to enable nurses, midwives and members of the
  multidisciplinary health care team to devise and
  implement medication protocols
• to enable the education and training of nurses
  and midwives involved in the use of such
  protocols
• to disseminate information to all members of
  the health care team regarding organisational
  policies underpinning the use of medication
  protocols
• to establish review and audit processes to
  evaluate the use of medication protocols as part
  of quality assurance and risk management
  programmes.

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Recommendation 2 Expansion of the Use of
Medication Protocols

• It is recommended that an explicit legislative
  basis be provided for the supply and
  administration of medicinal products using
  medication protocols by nurses midwives in
  hospital community settings.

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Recommendation 3Supply Administration of
OTCs

• Nurses and midwives should be enabled to supply
  and administer over-the-counter medications in
  accordance with their competence within their
  scope of practice supported by medication
  protocols where appropriate.

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Action 3.1 Professional Guidance

• An Bord Altranais will revise the current
  Guidance to Nurses and Midwives on Medication
  Management to incorporate guidance for the
  professions to supply administer
  over-the-counter medications.

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Action 3.2 Health Service Provider Responsibility

• Provision should be made by the health service
  provider for the development and implementation
  of policies to support the supply
  administration of over-the-counter medications by
  nurses and midwives in health care settings.
• The provisions as detailed in Action 1.2 should
  also be made available for this action involving
  over-the-counter medications.

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Recommendation 4 Prescriptive Authority

• Prescriptive authority should be extended to
  nurses and midwives, subject to regulations under
  the relevant legislation by the Minister for
  Health and Children regulation by An Bord
  Altranais.

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Action 4.1 Legislation

• A review and subsequent enactment and/or
  amendment of all relevant primary secondary
  legislation is required in order to introduce
  prescriptive authority for nurses and midwives.
  This is a matter for the Department of Health and
  Children.

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Action 4.2 Professional Regulation Guidance

• The criteria for nurse/midwife prescribing must
  be established. This will require defining the
  scope of practice for which prescriptive
  authority will be granted.
• It is recommended that the establishment of
  criteria for nurse/midwife prescribing should be
  the responsibility of An Bord Altranais.

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Action 4.3 Professional Regulation Guidance

• The standards and requirements in respect of the
  education training leading to prescriptive
  authority for nurses midwives must be
  established.
• It is recommended that the establishment of such
  standards and requirements should be the
  responsibility of An Bord Altranais.

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Recommendation 5 Implementation of the
Recommendations Actions

• An Bord Altranais the National Council should
  establish a Project Implementation Team to work
  in consultation with key stakeholders to
  facilitate the implementation of these
  recommendations actions.

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Thank you to all who have contributed to this
Review