Making a difference - the benefits and challenges of non-medical prescribing
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This presentation by Nikki Embrey from the North Midland MS Service looks at the benefits of and barriers to nurse prescribing, and whether it can make a difference to patient outcomes. It was presented at the MS Trust Annual Conference in November 2014.
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Making a difference - the benefits and challenges of non-medical prescribing
- 1. Making a difference – the benefits and challenges of non-medical prescribing Nikki Embrey RN MSc BSc (Hons) Nikki Embrey RN MSc North Midland MS Service North Midland University Hospital North Midlands University Hospital North nikki.embrey@uhns.nhs.uk nikki.embrey@uhns.nhs.uk
- 2. Introduction – how prescribing has influenced practice at UHNS • Nurse Prescribing – what it involves in clinical practice • What are the barriers to prescribing • What are the benefits? • Does it make a difference to patient outcomes? • Does it make a difference to the CNS’s role
- 3. Super Nurse?
- 5. Facts about Nurse Prescribing • 1998 first limited national formulary published for D/N’s & HV’s • 2002 – The NMC introduces the first independent nurse prescriber course • 2003 – Supplementary prescribing introduced (CMP). • 2004 – NMC changes nurse prescriber course to a dual independent/supplementary prescriber course • 2005 – NPEF extended • 2006 – Almost all of the BNF opened up to independent and supplementary nurse prescribers • Today - prevalence in community but growing number NP’s in Acute setting
- 7. MS Nurse prescribing UK
- 9. Pros and cons of NP
- 11. Argument for nurse prescribing • Specialist nurses become autonomous • Advances practice and empowers individual • Improves patient outcomes / access to treatments • Provides a more holistic approach.to care • Increases knowledge of pharmacology • Provides greater expertise in patient group • Enables dissemination for best practice • Increases flexibility, service efficiency • Helps support patient adherence and education • Improves satisfaction in the role.
- 12. The debate for nurse prescribing AIMING to improve quality of care and reduce access issues In Scotland evidence shows that: •Nurses are regarded as safe prescribers •Doctors workloads reduced •Public has considerable confidence in NP •NP believe their role is more effective
- 13. The debate FOR nurse prescribing • Increased nurse autonomy, job satisfaction, independence • Evidence shows it improves patient care – timely access to meds, increases flexibility service efficiency avoids unnecessary A/E visits and hospital admissions improves access to treatment – particularly in LTC • NP enables specialist nurses to educate service users and helps supports adherence to meds • Since NP patients report higher levels of satisfaction and confidence in nurses
- 14. Counter argument Independent prescribing • “the prescriber takes responsibility for the clinical assessment” of the patient, establishing a diagnosis, & the clinical management required as well as responsibility for prescribing where necessary and the appropriateness of any prescription”. (NPC 2006)
- 15. Debate against nurse prescribing
- 16. Why nurses should prescribe • A qualitative study on effectiveness of NP in acute setting found NO difference in prescribing methods of doctors and nurses IT increased patient satisfaction • Medication errors at the hands of NP are minimal • Benefits summary – consistently reported in literature: evidence shows improved care, satisfaction, better access to meds, reduced waiting times, higher quality of care delivered • AND • Need more empirical evidence (RCN Policy and International Dept. 2012)
- 17. Barriers to Nurse prescribing
- 19. Learning sets
- 20. Reflective incidents based on clinical practice Action Plans Improve the management of Relapse service Improved knowledge of pharmacology DMT’s Concordance
- 21. Assessment and examination of patients - Nursing assessment and patient examination skills fit well with Nurse prescribing – the two really should go hand-in-hand
- 22. Making a Difference in MS care • Relapse management – Infusion Suite and Out-patients • Disease modifying treatments - ALL • Symptom management – advice & recommendation • In-patient stays
- 23. How patients benefit – Access and prompt response to patients in relapse – Access to symptomatic management at appropriate time to meet their needs – Disease modifying therapies – choices of therapies, increased knowledge of drugs, pharmacology, adherence, side effect management
- 24. Assessment of Clinical Prescribing Preparation Competency Framework
- 25. New treatments in MS
- 28. Should MS practitioners prescribe? • YES – YOU are control • YES – YOU know the patient and condition • YES - You have the experience with MS Drugs • Yes – it is a better use of resources • YES – it makes clinical sense for long-term conditions • Resources to support
- 29. QUESTIONS 1. For those who are prescribers – what do you prescribe? 2. Those who do not prescribe – what reasons? 3. Those who are prescribers and don’t use it – why? 4. If you are thinking about prescribing – what has influenced you?
Editor's Notes
- Why I was an advocate of nurse Prescribing? Initially scary – exciting – NP reflects what is happening to medicine in this country and has happened over the last ten years. 12 years ago nurse prescribing was virtually unknown; prescribing was regarded as being a monopoly of the medical profession. Newly-qualified prescribers are already highly experienced practitioners who have been requesting medications for their patients for years (Ref). In my practice I seriously could not function as well without prescribing for my patients – this qualification has been invaluable Talking to my non-prescribing colleagues they feel they would do their job better by being a prescriber – finding it frustrating and time consuming not being able to ultimately write that prescription for that patient they have just assessed, investigated and diagnosed
- Positives We know our patients best Skilled, experienced competent to manage MS We are often prescribing anyway – recommending treatments to GP’s / patients / once told just by writing a recommended treatment on a scruffy piece of paper in a drop-in-clinic was actually prescribing unofficially! Patients would rather see a nurse – many reasons
- NP has grown significantly over the last decade Primarily due to efforts of stakeholders – DoH nurse regulators, nurse professional bodies, GP supporters – legislative and policy reforms in ACUTE and primary care settings from the Cumberledge Report in 1986 BNF gradually became available in part for D/N and H/V’s 1998 limited BNF for NP Initial objections from doctors have been abated due to improved access, patient safety, patient centred care – strengthen the foundations underpinning NP
- Long gone are the days where nurses stereo-typed into this! Our roles have moved on particularly over the last 15 years or so Many nurses are happy to remain in the ward or community environments, or general practice … …..BUT for the Clinical Nurse Specialist – diagnosing and treating is all part of the role - advancing practice and roles’’ has been fundamental to patients needs Why did we come into nursing – to ‘’Improve the lives of patients?’’ Initial objections from doctors have been abated due to improved access, patient safety, patient centred care – strengthen the foundations underpinning NP
- In a recent survey at CHARMS 2014 ‘’Looking at the National Picture’’ approximately 30% of MS nurses have done the NP course 1 person had not done the course but is actively prescribing 4 people had done the course but were are not prescribing Why would this be the case? Open to audience or leave to end?
- Nurse prescribing has to be your choice – but the benefits in my view out weigh ALL risks We will go onto explore the BENEFITS THE RISKS And BARRIERS for Independant prescribing Seriously need to consider what the BENEFITS are to you, your patient, your MS service, your Trust and all those working relationships …….. What can go wrong? What does go wrong? What does in entail? What is there to support you? How supportive is your Trust towards NP? How supportive are your team? Barriers to successful NMP Independent prescribing “the prescriber takes responsibility for the clinical assessment” of the patient, establishing a diagnosis, & the clinical management required as well as responsibility for prescribing where necessary and the appropriateness of any prescription”. (NPC 2006) DOES this may not happen in all cases? Major concern A lack of experience in assessment & diagnosis skills amongst nurses particularly in patients with complex or multiple conditions. Do we carry out a thorough assessment for those ? In relapse/ with increase tone/ neuropathic pain etc? Do we have accurate medical records detailing all medications the patients take/ previous medical conditions that we can be 100% confident in writing the prescription Competency We do not have rigorous, valid & reliable evidence of competence for specific clinical areas. No consistency in how competency is achieved and maintained Variations within teams/ departments/ Trusts. Closing argument Lack of clarity of what the role entails within the specialism generally and also within teams Continues to be management driven with no vision as to how it will impact on the service.
- If you are considering how it might impact your practice here are some thoughts…..
- We certainly do know our patients better than our Dr colleagues do in all areas – symptoms management, relapse and DMT THE Impact Nurse Prescribing has had on my practice: AUTONOMY ADVANCES ME AS A PRACTITIONER IMPROVES PATIENT OUTCOMES PROVIDES MORE HOLISTC CARE IMPROVES KNOWLEDGE IN PHARMACOLOGY SYMPTOM MANAGEMENT …. PROVIDES RIGOROUS TRAINING AND EXAMINATION GREATER EXPERTISE OF PATIENT GROUP ENABLES DISSEMINATION FOR BEST PRACTICE PLENTY OF RESOURCES AVAILABLE TO SUPPORT YOU IN ROLE OF PRESCRIBER
- Specialist nurses are more autonomous, advances practice and empowers improves patient outcomes. Provides a more holistic approach.to care. Increases knowledge of pharmacology and symptom management Provides greater expertise of a particular patient group, enables dissemination for best practice Increases flexibility, service efficiency, improves access to treatment. Helps support patient adherence and education. Improves satisfaction in the role.
- Qualification = NMC accredited prescribing course and registration with NMC On completion of NP course and after qualifying – can prescribe independently and supplementary
- Medical staff - holding nurses back in some centres – many may still be against NP Medical staff have to supportive in mentoring the nurse through the course Need supervised practice Need to feel supported in prescribing even years after course Need to feel you can ask someone if unsure – usually that is your MS Consultant Fortunate at stoke that Consultants were pro-nurse prescribing and they certainly are reaping the benefits now Major concern A lack of experience in assessment & diagnosis skills amongst nurses particularly in patients with complex or multiple conditions. Do we carry out a thorough assessment for those ? In relapse/ with increase tone/ neuropathic pain etc? Do we have accurate medical records detailing all medications the patients take/ previous medical conditions that we can be 100% confident in writing the prescription Competency Barriers to successful NMP Independent prescribing “the prescriber takes responsibility for the clinical assessment” of the patient, establishing a diagnosis, & the clinical management required as well as responsibility for prescribing where necessary and the appropriateness of any prescription”. (NPC 2006) Major concern A lack of experience in assessment & diagnosis skills amongst nurses particularly in patients with complex or multiple conditions. Do we carry out a thorough assessment for those ? In relapse/ with increase tone/ neuropathic pain etc? We do not have rigorous, valid & reliable evidence of competence for specific clinical areas. No consistency in how competency is achieved and maintained Variations within teams/ departments/ Trusts. Closing argument Lack of clarity of what the role entails within the specialism generally and also within teams Continues to be management driven with no vision as to how it will impact on the service. Inconsistency in policy regarding NMP Achieving & maintaining competency in NMP
- Do we lack of experience in assessment & diagnosis skills – or in patients with complex or multiple conditions. Do we carry out a thorough assessment for those ? In relapse/ with increase tone/ neuropathic pain etc? Do we have accurate medical records detailing all medications the patients take/ previous medical conditions that we can be 100% confident in writing the prescription Are we COMPETENT DO we do not have rigorous, valid & reliable evidence of competence for specific clinical areas. Is consistency in how competency achieved and maintained ARE there variations within teams/ departments/ Trusts. DO YOU know and are you clear on what YOUR role entails Have you decided for yourself and your patients that it is right OR does it continue to be management driven with no vision as to how it will impact on the service? Is there any inconsistency in policy regarding NMP? How will we achieve & maintain competency in NMP
- It is one of the best NURSING courses I have ever undertaken BUT…….. Barriers to successful NMP Independent prescribing “the prescriber takes responsibility for the clinical assessment” of the patient, establishing a diagnosis, & the clinical management required as well as responsibility for prescribing where necessary and the appropriateness of any prescription”. (NPC 2006) Major concern A lack of experience in assessment & diagnosis skills amongst nurses particularly in patients with complex or multiple conditions. Do we carry out a thorough assessment for those ? In relapse/ with increase tone/ neuropathic pain etc? Do we have accurate medical records detailing all medications the patients take/ previous medical conditions that we can be 100% confident in writing the prescription Competency We do not have rigorous, valid & reliable evidence of competence for specific clinical areas. No consistency in how competency is achieved and maintained Variations within teams/ departments/ Trusts. Closing argument Lack of clarity of what the role entails within the specialism generally and also within teams Continues to be management driven with no vision as to how it will impact on the service. Inconsistency in policy regarding NMP Achieving & maintaining competency in NMP Hard work – time management can be an issue Lot of work, with an increase of complexity, risk & litigation for little reward. Finding a good mentor How I dealt with the course, working, studying, supervision, reflection, Unsupportive medical staff. This si key to successful implementation. Need willing Drs to act as DMPs Organisational failures: out of date policies/ delay in adopting policies/ lack of monitoring/inconsistency or delay in procedures to regulate NMPs Differing courses at different educational institutions. Different approach to the course. All uphold the necessary regulatory requirements but methods of education and course content differs. Vast majority of courses geared towards community staff rather than staff in secondary care.
- What my course in 2006 involved Establishing a Portfolio – which still use today Exams x2 1)Seen Stem ‘’How does evidence based Prescribing and Clinical Governance impact on Nurse prescribing?’’ Ethics and nurse Prescribing - reference based 2) Short answer examination OSCI’s Supervised practice - Mentored time of 70 hours with Consultant clinics, teaching outside UNI, Phara, Pharmacists, etc… OSCI practice sessions I also undertook a Masters level assessment and Diagnostic course 12 weeks on patient examinations
- George Clooney sadly was not on my NP course, you needed to get used to presenting your learning on the NP course. 4 LEARNING Sets and in groups of 4’s-5 with nurses from the Region from various backgrounds, General and Mental health, investigated various conditions (not just Neurology or MS) Findings were presented to the whole group. This was useful learning because it enabled you to look at Pain Management, GI conditions, depression and MS (various others).
- Reflective Practice based on Gibbs reflective Cycle and ACTION PLANS devised to reflect learning – all in portfolio
- At the same time I did my NP I did OSCI’s with NP and masters degree involving Patient assessment and examination. It was difficult to do the 2 at the same time BUT they did go hand in hand and I am glad I did it this way now on reflection
- Nurses choice to extend roles How relapse clinics should be run Trusts views on hospital nurses prescribing Pharmaceutical opinions Patients opinions
- Support of mentors cannot be underestimated
- Important to maintain competency NP course encourages you to study medications in more detail – become more knowledgeable about effects, benefits, side effects mode of action …..
- Important also to look at evidence around Patient adherence to all therapies but in particular newer therapies with increased risk of side effects and little way of knowing how if they are compliant Expectations need to be challenged – feel more competent Advising GP’s and other drs – ensure you have a sound knowledge
- Why the Nurse Prescribing is important – TRUST requirement Provides boundaries ….know your limits prevents you from over stepping when challenged to prescribe something you are not competent to prescribe or have not assessed that patient
- THE Impact Nurse Prescribing has had on my practice: AUTONOMY ADVANCES ME AS A PRACTITIONER IMPROVES PATIENT OUTCOMES PROVIDES MORE HOLISTC CARE IMPROVES KNOWLEDGE IN PHARMACOLOGY SYMPTOM MANAGEMENT …. PROVIDES RIGOROUS TRAINING AND EXAMINATION GREATER EXPERTISE OF PATIENT GROUP ENABLES DISSEMINATION FOR BEST PRACTICE PLENTY OF RESOURCES AVAILABLE TO SUPPORT YOU IN ROLE OF PRESCRIBER