National Independent Evaluation of the Nurse and Midwife Prescribing Initiative. University College Dublin

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1 Natioal Idepedet Evaluatio of the Nurse ad Midwife Prescribig Iitiative Uiversity College Dubli

2 Natioal Idepedet Evaluatio of the Nurse ad Midwife Prescribig Iitiative Uiversity College Dubli Dr. Joatha Drea Dr. Coria Naughto Ms. Deirdre Alle Dr. Abbey Hyde Dr. Patrick Felle Dr. Kathy O Boyle Professor Pearl Treacy Dr. Michelle Butler This study was commissioed ad fuded by the Health Service Executive o behalf of the Natioal Resource ad Implemetatio Group o Nurse ad Midwife Prescribig i Irelad. Health Service Executive Jue 2009 ISBN: This report should be cited as Drea J., Naughto C., Alle D., Hyde A., Felle P., O Boyle K., Treacy P., Butler M. (2009) Idepedet Evaluatio of the Nurse ad Midwife Prescribig Iitiative. Uiversity College Dubli, Dubli.

3 Cotets Ackowledgemets Executive Summary ix x Chapter 1 Itroductio Backgroud to the Evaluatio Orgaisatio of the Evaluatio 1 Chapter 2 Developmet of Nurse/Midwife Prescribig i Irelad Itroductio Legislatio Guidig Nurse/Midwife Prescribig i Irelad Irish Medicies Board (Miscellaeous Provisios) Act Medicial Products (Prescriptio ad Cotrol of Supply) (Amedmet) Regulatios Nurses Rules Misuse of Drugs (Amedmet) Regulatios The Role of the Departmet of Health ad Childre ad the Health Service Executive i Nurse/Midwife Prescribig 2.4 The Role of A Bord Altraais i the Prescribig Iitiative Professioal Regulatio Educatio Cliical Goverace ad Professioal Guidace The Role of Health Service Providers i the Prescribig Iitiative Coclusio 8 4 Chapter 3 Literature Review Itroductio Iteratioal Developmets The Views of Health Professioals o Nurse/Midwife Prescribig Educatioal Preparatio ad Cotiuig Professioal Developmet of Nurse/Midwife Prescribers Educatioal Preparatio Etry to Prescribig Preparatio Programmes Cotiuig Professioal Developmet Patiet/Cliet Outcomes ad Nurse/Midwife Prescribig Patiet Attitudes to Nurse/Midwife Prescribig Patiet Satisfactio with Nurse/Midwife Prescribig Quality of Care Prescribig Safety Nurse/Midwife Prescribers Perceptios of their Role Coclusio Chapter 4 Research Desig Itroductio Purpose of the Evaluatio Aims of the Evaluatio 19

4 4.4 Desig of the Evaluatio Sample Sample of Nurse/Midwife Prescribers Sample of Patiets Sample of Stakeholders Phases of the Evaluatio Phase 1 - Evaluatio of Prescribig Preparatio Programmes Istrumets used to Measure Educatioal Outcomes Prescribig Outcomes Evaluatio Questioaire Reliability of the Prescribig Outcomes Evaluatio Questioaire Prescribers Course Experiece Questioaire Reliability of the Prescribig Course Experiece Questioaire Phase 2 - Audit of Nurse/Midwife Prescribig Aims of the Audit Objectives of the Audit Audit Site Selectio Prescriptio Sample Selectio Audit Data Collectio Applicatio of Medicatio Appropriateess Idex Validity ad Reliability of the Medicatio Appropriateess Idex Phase 3 - Evaluatio of Patiet Satisfactio with Nurse/Midwife Prescribig Measurig Patiet Attitudes Towards Nurse/Midwife Prescribig Measurig Patiets Satisfactio with Educatio/Advice Received Regardig their Medicatio Measurig Patiets Satisfactio with the Cosultatio Process Udertake by the Nurse/ 26 Midwife Prescriber - Cosultatio Satisfactio Questioaire Measurig Patiets Itetio to Comply with the Nurse/Midwife Prescriber s Prescriptio ad 27 Advice Demographic Data Collected from Patiets Procedure for Patiet Questioaire Desig ad Distributio Phase 4: Health Professioals Evaluatio of Nurse/Midwife Prescribig Phase 5: Nurse/Midwife Prescribers Evaluatio of their Role Procedure for Postal Surveys Data Aalysis Data Aalysis Quatitative Phases Data Aalysis Qualitative Phase Ethical Cosideratios Coclusio 31 Chapter 5 Evaluatio of Educatioal Preparatio of Nurse/Midwife Prescribig Itroductio Demographic, Professioal ad Academic Profile of Course Participats Evaluatio of Course Participats Level of Chage as a Outcome from the Educatioal 33 Preparatio Programme 5.4 Nurse/Midwife Prescribers Experiece of their Course of Study 37 ii

5 5.5 Course Participats Experiece of their Selectio for Prescribig Preparatio Programme 5.6 Cadidate Prescribers Experiece of the Registratio Process with A Bord Altraais followig Completio of the Prescribig Preparatio Programme 5.7 Coclusio Summary: Profile of Prescribers Summary: Key Fidigs from the Evaluatio of the Educatioal Preparatio Programme for Prescribers Chapter 6 Audit of Nurse/Midwife Prescribig Itroductio Aims ad Objectives of the Audit Overview of Orgaisatios Audited Nurses/Midwives Audited Profile of Patiet Records Audited Drugs Prescribed Audit of Safety Audit of Nurse/Midwife Prescribers Patiet Cosultatios Cosultatio Legibility Full Cosultatio Cotiuum of Care Cosultatios Patiet Cosultatio Summary Audit of Writte Prescriptios Legibility Patiet Idetificatio Drug Idetificatio ad Istructio Decisio ot to Prescribe Summary of Audit of Prescriptios Medicatio Safety ad Appropriateess Summary of Evaluatio of Medicatio Appropriateess Patiet Outcomes Summary: Profile RNPs ad Prescriptios Audited Summary: Key Fidigs from the Audit of Nurse/Midwife Prescribig 56 Chapter 7 Evaluatio of Patiets Level of Satisfactio with the Nurse/Midwife Prescribig Iitiative Itroductio Demographic Profile of Patiets/Service Users Surveyed Patiets Parets /Guardias Attitudes Towards Receivig a Prescriptio from a Nurse/ Midwife with Prescriptive Authority 7.4 Patiets Parets /Guardias Evaluatio of the Educatio ad Advice Received from a Nurse/Midwife with Prescriptive Authority 7.5 Patiets /Parets /Guardias Itetio to Comply with the Treatmet Prescribed Patiet Satisfactio with the Cosultatio Process with the Nurse/Midwife Prescriber Coclusio Summary: Key Fidigs from Patiets /Parets /Guardias Evaluatio of the Nurse/ Midwife Prescribig Iitiative iii

6 Chapter 8 Evaluatio of Stakeholders Perceptios of the Nurse/Midwife Prescribig Iitiative Itroductio Demographic Profile of Stakeholders 8.3 Stakeholders Attitudes towards the Nurse/Midwife Prescribig Iitiative Stakeholders Attitudes towards the Impact of the Iitiative o Patiet Care Stakeholders Attitudes towards the Safety of Nurse/Midwife Prescribig Stakeholders Attitudes Towards the Prescribig Iitiative Perceptio of Cliical Stakeholders with a Nurse/Midwife Prescriber i their 68 Orgaisatio Impact o Patiet Care The Impact of the Prescribig Iitiative o the Workload of Nurses/Midwives ad Doctors Cliical Stakeholders Perceptios of Commuicatio ad Collaboratio Coclusio Summary Key Fidigs from Stakeholders Evaluatio of the Nurse/Prescribig Iitiative 71 Chapter 9 Prescribers /No-Prescribers Evaluatio of the Nurse/Midwife Prescribig Iitiative Itroductio Evaluatio of the Prescribig Iitiative from the Perspective of Nurse/Midwife 73 Prescribers Curret Prescribig Practices Prescribers Assessmet of the Safety ad Ability of their Prescribig Role Impact of Nurse/Midwife Prescribig o Professioal Practice Prescribers Evaluatio of the Impact of their Role o Patiet Care Prescribers Evaluatio of Support Received for their Role Nurse ad Midwife Prescribers Evaluatio of Cotiuig Professioal Developmet Evaluatio of the Prescribig Iitiative from the Perspective of Nurse/Midwives who 80 Completed the Educatio Preparatio Programme but who are Curretly ot Prescribig 9.4 Coclusio Summary Key Fidigs from Nurse/Midwife Prescribers Evaluatio of the Prescribig Iitiative 82 Chapter 10 Qualitative Aalysis of the Perspectives of a Sample of Nurses/Midwives who have 84 Completed the Prescribig Preparatio Educatioal Programme 10.1 Itroductio Becomig a Nurse/Midwife Prescriber Educatioal Preparatio to Become a Nurse/Midwife Prescriber Preparig to Practice as a Nurse/Midwife Prescriber: Barriers, Supports ad Processes The Experiece of Prescribig Limitatios to the Rage of Drugs that a Nurse/Midwife Ca Prescribe Coceptualisig Prescribig as a Nursig Midwifery Fuctio Itegrated Care Moitorig ad Auditig of Nurse/Midwife Prescribig Coclusio 92 iv

7 Chapter 11 Discussio ad Coclusio Itroductio Profile of Nurse/Midwife Prescribers Safety ad Competecy to Prescribe Prescribers Evaluatio of their Educatio Programme Commuicatio ad Support for the Prescribig Role Patiets Evaluatio of Nurse/Midwife Prescribig Prescribers Evaluatio of their Role Coclusio 100 Chapter 12 Recommedatios Coclusive Fidig ad Geeral Recommedatio Recommedatio I - Overall Recommedatio Supportig Recommedatios Recommedatio II - Ulicesed Medicatios Recommedatio III - Prescribig Medicatios Outside their Terms of Licece (Off-Label Medicatios) Recommedatio IV - Prescribig of Cotrolled Drugs Recommedatio V - Educatio of Nurse/Midwife Prescribers Recommedatio VI -Registratio of Nurse/Midwife Prescribers Recommedatio VII - Cotiuig Professioal Developmet Recommedatio VIII - Collaborative Practice Agreemet Recommedatio IX - Prescribig Practice Recommedatio X - Future Developmets Refereces 104 Appedices Appedix I Educatioal Outcomes Evaluatio Questioaire 110 Appedix II Audit Tools 120 Appedix III Patiet Questioaire 123 Appedix IV Stakeholders Questioaire 127 Appedix V Prescribers ad Curretly ot Prescribig Questioaires 133 v

8 List of Figures Figure 5.1 Cliical Grade of Course Participats 32 Figure 5.2 Highest Academic Qualificatio held by Course Participats 32 Figure 5.3 Course Participats Ratigs of their Uderstadig ad Ability i each of the Prescribig 37 Domais Before ad After the Educatioal Programme Figure 5.4 Course Participats Overall Levels of Satisfactio with the Metorig Process 38 Figure 5.5 Course Participats Overall Levels of Satisfactio with the Prescribig Preparatio Programme 41 Figure 5.6 Mea Scores o the Scales of the PCEQ 42 Figure 6.1 Areas RNPs Prescribig ad Number of Prescriptios 46 Figure 6.2 Reaso Patiets Preseted for Treatmet 47 Figure 6.3 Reasos why Drugs were Prescribed 47 Figure 6.4 Type of Drugs Prescribed 47 Figure 7.1 Patiets Ratigs of their Overall Health 57 Figure 7.2 Coditio for Which Medicatio was Prescribed 57 Figure 7.3 Patiets Attitudes Towards Nurse/Midwife Prescribig 58 Figure 7.4 Patiets Level of Agreemet/Disagreemet to the Statemet I would Prefer a Doctor to 58 Prescribe my Medicatio Figure 7.5 Patiet/Paret Level of Agreemet to the Statemet Receivig a Prescriptio from a Nurse/ 60 Midwife Reduced my Waitig Time Figure 7.6 Itetio to Comply with a Prescriptio Admiistered by a Nurse/Midwife by Health Status 60 Figure 7.7 Respodets Itetio to Comply with Treatmet Prescribed by a Nurse/Midwife Prescriber by 61 Geder ad Overall Health Figure 7.8 Patiets Level of Agreemet to the Statemet Overall I was Satisfied with this Cosultatio from 62 the Nurse/Midwife Figure 7.9 Respodets Level of Satisfactio with their Cosultatio with the Nurse/Midwife Prescriber by 63 Geder Figure 7.10 Respodets Level of Satisfactio with their Cosultatio with the Nurse/Midwife Prescriber by 63 Health Status Figure 8.1 Demographic Profile of Stakeholders 65 Figure 8.2 Attitudes Towards the Impact of the Prescribig Iitiative o Patiet Care by Professioal Group 66 Figure 8.3 Attitudes to the Statemet I trust Nurses/Midwives to Prescribe Correctly by Professioal 67 Group Figure 8.4 Attitudes to the Statemet I am Worried that Nurses/Midwives do ot have the Kowledge to 67 Prescribe by Professioal Group Figure 8.5 Key Stakeholders Respose to the Statemet Overall the Itroductio of the Nurse/Midwife 68 Prescribig Iitiative has bee a Success Figure 8.6 Attitudes Towards the Statemet The Itroductio of the Nurse/Midwife Prescribig Iitiative 69 had Reduced Delays i the Discharge of Patiets Figure 8.7 Attitudes Towards the Statemet The Itroductio of the Nurse/Midwife Prescribig Iitiative is 70 more Coveiet for Patiets Figure 8.8 Attitudes Towards the Statemet The Itroductio of the Nurse/Midwife Prescribig Iitiative 70 has Eabled Patiets to Access Medicatio Quicker Figure 8.9 Attitudes Towards the Statemet The Itroductio of the Nurse/Midwife Prescribig Iitiative has had a Positive Impact o Iterprofessioal Relatioships 71 vi

9 Figure 9.1 Frequecy of Prescribig 73 Figure 9.2 Levels of Job Satisfactio Associated with the Prescribig by Years Qualified 75 Figure 9.3 Prescribers Level of Agreemet o the Impact of the Prescribig Iitiative o Patiet Care 76 Figure 9.4 Compariso of Stakeholders ad Prescribers Attitudes Towards the Coveiece of the 78 Prescribig Iitiative for Patiets/Cliets Figure 9.5 Compariso of Stakeholders ad Prescribers Attitudes Towards Patiet Access to Medicatio 78 sice the Itroductio of the Iitiative Figure 9.6 Support from Prescribig Site Co-ordiator 78 Figure 9.7 Support from Prescribig Metor 79 Figure 9.8 Support from Health Service Executive 79 Figure 9.9 Support from Doctors/Cosultats 79 Figure 9.10 Proportio of Prescribers who have Udertake Formal CPD Relevat to Nurse/Midwife Prescribig 79 vii

10 List of Tables Table 4.1 Reliability Estimates of the POEQ Scales 23 Table 4.2 Reliability Estimates of the PCEQ Scales 24 Table 4.3 Reliability Estimates of the CSQ Scales 27 Table 5.1 Course Participats Uderstadig ad Ability i each of the Items Withi the Prescribig 34 Educatioal Domais Table 5.2 Course Participats Uderstadig ad Ability i each of the Prescribig Educatio Domais 37 Table 5.3 Course Participats Resposes to the Items o the PCEQ 39 Table 5.4 Mea Scores of the Prescribers Course Experiece Questioaire 41 Table 6.1 Cotet of Nurse/Midwife Prescribers Patiet Cosultatios 50 Table 6.2 Patiet Idetificatio Criteria for Nurse/Midwife Prescriptio Writig 52 Table 6.3 Accuracy ad Clarity of Drug Details i Prescriptios 53 Table 6.4 Medicatio Appropriateess Idex 55 Table 6.5 Outcome Data for Patiets i Audit 56 Table 7.1 Patiets /Parets /Guardias Evaluatio of the Educatio ad Advice Received from a Nurse/ 59 Midwife with Prescriptive Authority Table 7.2 Patiets /Parets /Guardias Resposes to the Items o the Compliace Itet Subscale 61 Table 7.3 Patiets /Parets /Guardias Resposes to the Items o the Cosultatio Satisfactio Scale 62 Table 7.4 Mea Scores of the Scales of the Cosultatio Satisfactio Questioaire 62 Table 8.1 Stakeholders Attitudes Towards the Impact of the Iitiative o Patiet Care 66 Table 8.2 Stakeholders Attitudes Towards the Safety of the Prescribig Iitiative 66 Table 8.3 Stakeholders Attitudes Towards the Prescribig Iitiative 67 Table 8.4 Cliical Stakeholders Perceptios of the Impact of the Prescribig Iitiative o Patiet/Cliet Care 69 Table 8.5 Cliical Stakeholders Perceptios of the Impact of the Prescribig Iitiative o Nurses /Midwives 70 ad Doctors Workloads Table 9.1 Prescribers Assessmet of the Safety of their Prescribig Role 74 Table 9.2 Impact of the Iitiative o the Professioal Role of Nurse ad Midwife Prescribers 75 Table 9.3 Prescribers Perceptios of the Impact of the Prescribig Iitiative o Patiet/Cliet Care 76 Table 9.4 A Compariso of Cliical Stakeholders ad Prescribers Perceptios of the Impact of the 77 Prescribig Iitiative o Patiet/Cliet Care Table 9.5 Reasos Advocated for Delay i Iitiatig Prescribig 81 viii

11 Ackowledgemets The research team would like to thak the followig for their support ad advice throughout the evaluatio of the prescribig iitiative: Professor Kare Luker, Professor/Dea of the School of Nursig, Midwifery ad Social Work, Uiversity of Machester who acted as a exteral idepedet advisor to the evaluatio. Professor Luker s kowledge, expertise ad advice o urse/midwife prescribig was ivaluable. Our colleagues at the School of Nursig, Midwifery ad Health Systems, The School of Medicie ad Medical Sciece ad the School of Biomolecular ad Biomedical Sciece at Uiversity College Dubli for support throughout the study. Ms Isabel Hidalgo of the School of Nursig, Midwifery ad Health Systems for excellet admiistrative support provided throughout the evaluatio. Directors/Assistat Directors of Nursig ad Midwifery for facilitatig access to cliical sites. A special word of thaks to Prescribig Site Coordiators who orgaised access to sites ad to patiet records. The help of Prescribig Site Coordiators was particularly valuable i facilitatig the successful completio of the evaluatio. Stakeholders, patiets, service users ad parets who gave so geerously of their time i completig the survey questioaires. Professor Molly Courteay, Professor of Prescribig ad Medicies Maagemet, School of Health ad Social Care, Readig Uiversity ad Professor Sue Latter, Professor of Nursig, School of Health Scieces, Uiversity of Southampto, for permissio to use ad adapt questioaires used i this evaluatio. The Health Service Executive ad the Natioal Resource ad Implemetatio Group for Nurse ad Midwife Prescribig for providig Uiversity College Dubli with the opportuity to udertake the evaluatio. The Evaluatio Steerig Group which icluded: Ms. Mary Brosa, Director of Midwifery ad Nursig, Natioal Materity Hospital, Mr Paul Catwell Assistat Pricipal Officer, Nursig Policy Divisio, Departmet of Health ad Childre, Professor Seamus Cowma, Professor of Nursig ad Midwifery, Head of School of Nursig, Royal College of Surgeos i Irelad, Dr. Kathlee MacLella, Head of Professioal Developmet, Natioal Coucil for the Professioal Developmet of Nursig ad Midwifery, Professor Geraldie McCarthy, Professor of Nursig ad Midwifery, Head of School of Nursig ad Midwifery, Uiversity College Cork, Dr. Ae-Marie Rya, Chief Educatio Officer A Bord Altraais. Fially, the evaluatio would ot have bee possible without the help ad support of urse ad midwife prescribers. The evaluatio team are grateful to prescribers for gratig access to their prescribig records, facilitatig questioaire distributio to patiets ad makig themselves available for iterview. ix

12 Executive Summary Backgroud to the Evaluatio The developmet of urse ad midwife prescribig i Irelad was iitiated by recommedatios i two key reports, the Commissio o Nursig (Govermet of Irelad, 1998) ad the Review of Scope of Practice for Nursig ad Midwifery: Fial Report (A Bord Altraais, 2000). Followig o from the recommedatios i these two key reports A Bord Altraais ad the Natioal Coucil for the Professioal Developmet of Nursig ad Midwifery udertook a joit project with the aim of explorig the potetial of extedig prescriptive authority to urses ad midwives. This collaborative project resulted i the publicatio of A Review of Nurses ad Midwives i the Prescribig ad Admiistratio of Medicial Products (A Bord Altraais/Natioal Coucil for the Professioal Developmet of Nursig ad Midwifery 2005). This review recommeded that prescriptive authority should be exteded to urses ad midwives. Followig this recommedatio the Miister for Health ad Childre, Mary Harey TD, published the Irish Medicies Board (Miscellaeous Provisios) Act, 2006 allowig for the itroductio of urse ad midwife prescribig. By 2007 these recommedatios were siged ito law. I effect the Act for the first time i Irelad allowed urses to prescribe idepedetly. The Miister for Health ad Childre gave a commitmet to coduct a review of the regulatios two years followig their implemetatio to esure they were workig as plaed. This report outlies the fidigs from a atioal idepedet evaluatio of the urse/midwife prescribig iitiative that was udertake as part of the two year review. A research team from the School of Nursig, Midwifery ad Health Systems, the School of Medicie ad Medical Sciece ad the School of Biomolecular Sciece, Uiversity College Dubli udertook the evaluatio. Purpose of the Evaluatio The purpose of the evaluatio was to examie the effectiveess i practice of the itroductio of idepedet urse ad midwife prescribig ad to establish if the model adopted for implemetatio had achieved the stated objectives i terms of quality, patiet safety, commuicatio ad patiet/cliet beefits ad satisfactio. Aims of the Evaluatio The aims of the evaluatio were based o the specific research questios idetified by the Steerig Group for the Idepedet Exteral Evaluatio of the Nurse ad Midwife Prescribig Iitiative ad icluded: 1) to evaluate urse ad midwife prescribig from a service perspective; 2) to evaluate the curret ad potetial outcomes of urse ad midwife prescribig i terms of patiet/cliet beefits, safety ad satisfactio; 3) to take ito accout the views of key stakeholders, particularly employers, urses ad midwives, medical ad pharmacy professios ad the Regulatory bodies (Office of the Nursig Services Director, Health Service Executive 2008a). Phases of the Evaluatio Five distict but iterliked phases of research were carried out. The overall aim of this approach was to eable key stakeholders have a voice i the evaluative process. The five phases were as follows: 1. Evaluatio of Educatioal Preparatio of Nurses ad Midwives for Prescribig Practice. 2. Audit of Nurse/Midwife Prescribig. 3. Evaluatio of Patiet Satisfactio with the Prescribig ad Cosultatio Process. 4. Nurses ad Midwives Perceptios of Outcomes from the Prescribig Iitiative icludig Patiet/Cliet Beefits, Safety ad Commuicatio. 5. Evaluatio of Health Professioals Perceptios of Outcomes from the Prescribig Iitiative icludig Patiet/Cliet Beefits, Safety ad Commuicatio. Key Stakeholders Ivolved i the Evaluatio Those who have a iterest i the urse/midwife prescribig iitiative were idetified i the evaluatio as stakeholders ad were a importat part of the evaluatio process. Therefore the evaluatio took ito accout the views of key stakeholders, icludig employers, urses ad midwives (icludig prescribers ad o-prescribers), the medical ad pharmacy professios, regulatory bodies ad patiets ad cliets x

13 who had cotact with urse/midwife prescribers. For each phase of the evaluatio a sample of stakeholders was geerated. I total 138 urses/midwives who had completed the prescribig educatioal programme, over 300 patiets from eightee health service providers who had received a prescriptio from a urse/midwife with prescriptive authority ad 456 key stakeholders were surveyed. Key stakeholders icluded urse/midwife cliicias, maagers ad admiistrators, pharmacists (both hospital ad commuity based), academics ad medical doctors as well as key stakeholders i each of the regulatory ad policy bodies icludig A Bord Altraais, Natioal Coucil for the Professioal Developmet of Nursig ad Midwifery, Departmet of Health ad Childre, the Health Service Executive ad uios represetig urses ad midwives. Chairs of hospital drugs ad therapeutics committees were also surveyed, as were represetatives from the Irish Medicies Board, the Irish Medical Coucil ad the Pharmaceutical Society of Irelad. I additio a total of eightee urses ad midwives who had completed the prescribig preparatio programme were iterviewed for the qualitative phase of the study. Furthermore, a audit of urse/midwife prescribers prescriptios ad cosultatios was udertake i eight separate health service providers. Of the 138 urse/midwives who completed the educatioal preparatio programme for prescribig practice 102 respoded to the educatio ad prescribig practice survey resultig i a respose rate of 74%. A total of 335 stakeholders out of a total of 456 cotacted completed the stakeholder compoet of the survey which resulted i a respose rate of 71.5%. Of the 310 patiets surveyed 140 retured questioaires, this resulted i a respose rate of 45%. Data Collectio Data for the evaluatio was collected from a umber of sources icludig surveys, audit of prescriptios ad patiet records ad iterviews. A umber of survey questioaires were developed or modified specifically for this evaluatio ad icluded istrumets that measured outcomes associated with the prescribig preparatio programme ad a questioaire that measured the quality of the course completed by cadidate prescribers. A questioaire was also developed that measured patiets attitudes towards urse/midwife prescribig, their satisfactio with the level of advice ad educatio received o the medicatio prescribed, their itetio to comply with the prescriptio admiistered by a urse/ midwife prescriber ad their overall satisfactio with the urse/midwife prescriber cosultatio process. Survey istrumets were developed that measured urse/ midwife prescribers ad other stakeholders evaluatio of key areas related to prescribig icludig regulatio ad guidace, educatioal preparatio, factors facilitatig ad ihibitig prescribig opportuities, moitorig processes, patiet safety, teamwork ad commuicatio, impact of urse/midwife prescribig o the work of other health professioals, quality of care ad overall merit of urse/ midwife prescribig. Furthermore key cliical stakeholders who had day-to-day cotact with urse/midwife prescribers evaluated the impact that the prescribig iitiative had o patiet care, ad the impact that it had o ursig, midwifery ad medical teams. A separate survey was admiistered to urses ad midwives who had completed the prescribig preparatio programme but were ot yet prescribig. The aim of this phase of the survey was to idetify reasos why this cohort had ot yet commeced prescribig ad to idetify their future plas i relatio to developig their prescribig practice. The qualitative phase of the evaluatio cosisted of semi-structured i-depth iterviews with urses ad midwives who were curretly prescribig ad those who had ot yet commeced prescribig at the time of the evaluatio. I the audit phase of the study a istrumet etitled the Medicatio Appropriateess Idex evaluated the appropriateess of the prescriptio admiistered by the urse/midwife prescriber for the treatmet of a patiet i their care. This audit resulted i a review of twety-five urse/midwife prescribers prescriptios ad cosultatios. Data was collected o 208 drug items prescribed to a total of 142 patiets. Fidigs Key Fidigs from the Evaluatio of the Educatioal Preparatio Programme for Prescribers Nurse ad midwife prescribers who had completed the prescribig preparatio programme had extesive cliical experiece ad the majority were employed at higher ursig grades. Practically all respodets held a third-level qualificatio with over half educated to master s level. Course participats reported that xi

14 Executive Summary (cotiued) they had gaied ability i a umber of key areas as a cosequece of their prescribig preparatio programme ot least i areas related to accoutability, legislatio, pharmacology ad applicatio of the prescribig process to professioal practice. The greatest gais were made by course participats i relatio to their overall ability ad self-cofidece to prescribe, a uderstadig of pharmacology ad pharmacotherapeutics ad a uderstadig of the legal ad ethical aspects of prescribig practice. The majority of course participats were satisfied with the quality of teachig o their educatio programme. The assessmet process was also highly rated by cadidate prescribers with high levels of satisfactio recorded for the both the theoretical ad cliical assessmet processes used throughout the preparatio programmes. Respodets also reported that the programme had prepared them for prescribig practice, however a umber of participats were dissatisfied with the level of preparatio they received for their particular area of specialist practice. There was also variability i respodets perceptio of the workload throughout the course ad it was the oly aspect of the prescribig preparatio programme that was rated egatively overall. The most positive aspect of the prescribig programme was the high level of satisfactio expressed by course participats at the support they received from their medical practitioer metor. Course participats geerally perceived that the educatio programmes were well orgaised however there was some variatio i respodets uderstadig of the level of work expected of them throughout the course. I coclusio the educatioal preparatio programmes provided studets with a broad rage of educatioal experieces i the area of prescribig practice. It is evidet that the educatio delivered through these programmes had a positive impact o studet learig ad led to substatial chage i course participats ability to prescribe. It is also evidet from the overall fidigs that course participats received a quality educatioal experiece ad that studets were geerally satisfied with the orgaisatio ad delivery of the programmes. Key Fidigs from the Audit of Nurse/Midwife Prescribig Twety-five urse/midwife prescribers were icluded i the audit; this represeted 81% of registered urse/ midwife prescribers from eight hospitals ad 44% of all registered urse/midwife prescribers i practice at the time of the evaluatio. I total 142 patiet records, which cotaied evidece of Nurse/Midwife prescribig, were audited. Two hudred ad eight drug items were prescribed for the 142 patiets icluded i this audit. This compoet of the study foud that, overall, the evidece showed that the majority of urse/midwife prescribig audited was appropriate ad safe. There was some variability i quality of the recordig of cosultatios however there were also examples of excellet practice. Furthermore, the cotext of the cosultatio ad the ratioale for the prescriptio issued was idicated i the majority of documeted cosultatios reviewed. Prescriptios were, overall, writte to a high stadard with the ame of the drug, dosage ad frequecy of the medicatio clearly idetified i the majority of prescriptios audited. However there was some variability i the recordig of the duratio of therapy. The vast majority of medicatios prescribed were idetified as beig the correct treatmet for the medical coditio idetified i the cosultatio ad medical records. A small umber of drugs prescribed were idetified as havig the potetial to iteract with other medicatios that the patiet was takig but overall i the vast majority of prescriptios reviewed there were o potetial iteractios idetified. Furthermore i the vast majority of prescriptios ad cosultatios audited there was o evidece of a adverse reactio to the medicatio prescribed by the urse/midwife prescriber. Key Fidigs from Patiets /Cliets Evaluatio of the Nurse/Midwife Prescribig Iitiative Patiets ad parets of childre who received a prescriptio from a urse/midwife with prescriptive authority were highly satisfied with the care they received from urse/midwife prescribers ad the majority were of the opiio that urses ad midwives should be able to prescribe. Patiets/parets also reported that they received comprehesive educatio ad advice from the urse/midwife prescriber o the medicatio prescribed. Waitig time was also perceived to have bee impacted upo with over iety per cet of patiets reportig that it had reduced their waitig time for treatmet. Patiet s itet to comply with the advice regardig the medicatio prescribed was high, idicatig that patiets trusted the educatio ad advice provided by the urse/midwife prescriber. Overall satisfactio with the cosultatio process was also high with the majority of patiets surveyed of the opiio that the urse/midwife prescriber was comprehesive i the delivery of their care, listeed to their cocers ad treated them as a xii

15 perso. Patiets were also satisfied with the time the urse/midwife prescriber spet with them durig the cosultatio process; however some patiets, especially those reportig poorer health, would like to have spet more time with the urse/midwife. Overall there were high levels of support for the prescribig iitiative with the vast majority of patiets i favour of urse/midwife prescribig. Patiets were also satisfied with the care ad advice provided by prescribers ad reported high levels of itet to comply with the prescriptio admiistered by a urse or midwife. Key Fidigs from Stakeholders Evaluatio of the Nurse/Prescribig Iitiative There was a high level of support from key stakeholders (urses, midwives, medical practitioers, pharmacists, regulatory ad policy persoel) towards the itroductio of the iitiative with the majority of respodets of the opiio that urse/midwife prescribig was a good service for patiets, that it had a positive impact o patiet care ad that it also met the eeds of patiets. There was also agreemet that extedig prescriptive authority to urses ad midwives was safe with the majority of stakeholders i agreemet that urses ad midwives would prescribe correctly, that they had the kowledge to prescribe ad that prescribers had received appropriate educatio ad traiig for their role. The majority of stakeholders were also of the opiio that urses ad midwives had a role i the prescribig process ad there was a eed to exted prescribig beyod the remit of the medical professio. Stakeholders were very supportive of the iitiative overall ad two-thirds of respodets were of the opiio that its itroductio had bee a success. However, a quarter had o opiio o the success or otherwise of the itroductio of the prescribig iitiative reflectig the recet itroductio of urse/midwife prescribig i some sites. Stakeholders that worked directly with a urse/midwife prescriber i their orgaisatio idetified the ability of patiets to access medicatio more quickly ad efficietly as a key outcome from the prescribig iitiative. There was also a perceptio that it had reduced the umber of health professioals a patiet had to iteract with durig their visit or stay i hospital. Cliical stakeholders were also of the opiio that urse/midwife prescribig impacted positively o a umber of patiet outcomes such as patiet satisfactio ad compliace. Although there was variability i opiio o the impact of urse/midwife prescribig o the frequecy with which patiets with log-term illess had to visit their doctor for a prescriptio ad the extet to which it reduced delays i the discharge of patiets, a small majority of cliical stakeholders agreed that urse/midwife prescribig had impacted positively o these outcomes. However, whilst the majority of urse/midwife prescribers agreed that the prescribig iitiative reduced the delay i the discharge of patiets, the majority of medical practitioers disagreed. There was cosesus amogst cliical stakeholders that the extesio of prescriptive authority had freed up doctors time. Furthermore medical practitioers perceived that supervisig a urse/midwife prescriber was ot, overall, a burde o their workload. It was also evidet that the majority of cliical stakeholders were of the opiio that urse ad midwife prescribers were supported i their role by other health professioals withi the orgaisatio withi which they were based. Key Fidigs from Nurse/Midwife Prescribers Evaluatio of the Prescribig Iitiative Sice commecig prescribig the vast majority of urses ad midwives reported that they were prescribig o a frequet basis with, o average, each prescriber admiisterig approximately ie prescriptios per week. Over half of the prescribers reported that they admiistered less tha five prescriptios per week. A majority of prescribers reported that there were drugs ad medicatios that they would like to prescribe as part of their cliical practice but were uable to do so. The pricipal reaso for this costrait was their iability to prescribe ulicesed medicatios. Aother costrait o prescribig practice, especially for those prescribers workig i pai maagemet, was the limits placed o the prescribig of cotrolled drugs by Schedule 8 of the Misuse of Drugs (Amedmets) Regulatios I certai sites urse/midwife prescribers were prohibited from prescribig atibiotics by their local Drugs ad Therapeutics Committee. The majority of prescribers agreed that they could prescribe safely ad effectively ad that they had received the ecessary skills ad traiig to fulfil their role as a prescriber. They were also aware of their scope of practice ad the issue of accoutability associated with a prescribig role. Although a majority of respodets were cofidet i their ability to make a diagosis ad to write a prescriptio a miority expressed some cocer regardig these facets of their role. A substatial miority of prescribers also expressed cocer at the possibility of litigatio associated with their role. xiii

16 Executive Summary (cotiued) The evaluatio foud that the extesio of prescriptive authority to urses ad midwives has had a positive impact o their cliical role; i particular it had ehaced their professioal developmet, icreased their overall job satisfactio ad ehaced the care that they ca ow deliver to patiets. Furthermore, urses ad midwives were of the opiio that the their ability to prescribe had improved the quality of care they could deliver to patiets, esured better use of their skills ad icreased their professioal autoomy. Nurses ad midwives did ot perceive that the additio of a prescribig role had impacted o their core ursig ad midwifery skills however a majority reported that it had resulted i a icreased workload. There was a geeral cosesus amog prescribers that the itroductio of prescriptive authority for urses has had a positive impact o a umber of aspects of patiet care icludig eablig patiets access medicatios quicker tha before, eablig i-patiets to commece treatmet earlier ad icreasig patiet compliace with the medicatio prescribed. I comparig prescribers opiios with that of cliical stakeholders o the beefits of urse/midwife prescribig it was evidet that there was cosesus amogst the two groups that it had bee a positive additio to the provisio of patiet care. Nurses ad midwives with prescriptive authority were highly satisfied with the level of support they received for their role at both local ad atioal levels. It was evidet that prescribers were overall supported withi their orgaisatio to help them develop their role. Support was high from medical ad pharmacy colleagues as well as from their ursig ad midwifery colleagues. At atioal level prescribers reported that they were well supported i their role by both the HSE ad A Bord Altraais. The level of support urse ad midwife prescribers received from other health professioals ad the structures put ito place by the HSE ad A Bord Altraais was coducive to the overall success of the iitiatio of the iitiative. The experiece of prescribers i relatio to cotiuig professioal developmet was variable. While the majority reported that they had ot accessed ay form of formal cotiuig professioal developmet related to prescribig followig the completio of their prescribig educatio programme all prescribers reported that they egaged i some form of iformal cotiuig professioal developmet. The area i which prescribers idetified that they required ogoig professioal developmet was pharmacology. The majority of urses ad midwives who had completed the prescribig preparatio programme but were ot yet prescribig at the time of the survey iteded to do so i the ear future. Of those who iteded to commece prescribig, agreeig their Collaborative Practice Agreemet with their local Drugs ad Therapeutics committee was the mai barrier to iitiatig prescribig practice. Coclusio I coclusio the extesio of prescriptive authority to urses ad midwives has bee a positive developmet, ot oly for the impact it has had o the professioal developmet of urses ad midwives but also for the impact that it has had o patiet care. From the perspective of urse/midwife prescribers it has icreased their autoomy, icreased levels of job satisfactio, esured better use of their skills ad ultimately has allowed them to provide holistic care to patiets. For may urses ad midwives this was a aspect of their role that was missig. Patiets are highly supportive ad acceptig of the iitiative ad it is evidet that it reduces waitig times ad facilitates them i accessig treatmets that previously they would have had to wait for. It is also evidet that overall there is support for urse/midwife prescribig from those surveyed from the ursig, midwifery, medical ad pharmacy professios although levels of support i some cases are variable. There are a umber of issues that eed to be resolved icludig further commuicatio with the various groups of health professioals, issues associated with the documetatio of prescribig cosultatios, the reductio of the admiistrative burde o prescribers ad the further developmet of the iitiative to esure that urses ad midwives with prescriptive authority become idepedet i their prescribig practice. The pricipal barriers to the further developmet of prescribig practice for urses ad midwives iclude issues surroudig the prescribig of ulicesed medicatios ad the limitatios placed o the prescribig of cotrolled drugs. Cadidate prescribers agreeig collaborative agreemets with their local Drugs ad Therapeutics Committees has also bee idetified as a barrier i some areas to the developmet of the role. Overall, based o the fidigs from this evaluatio the idepedet atioal evaluatio recommeds that the atioal rollout of idepedet urse/midwife prescribig cotiue ad be further supported ad stregtheed. xiv

17 Recommedatios 1.1 Coclusive Fidig ad Geeral Recommedatio This evaluatio has foud that overall the iitiative for idepedet urse ad midwife prescribig has bee safely developed ad implemeted o a atioal basis Recommedatio I The idepedet atioal evaluatio recommeds that the atioal rollout of idepedet urse/midwife prescribig cotiue ad be further supported ad stregtheed through the implemetatio of the recommedatios outlied below. 1.2 Supportig Recommedatios Recommedatio II Ulicesed Medicatios It is evidet from the fidigs of this idepedet evaluatio that a major barrier for urse ad midwife prescribers is their iability to prescribe ulicesed medicatios. This is a particular problem for prescribers i the areas of childre s ursig ad eoatal care, however it also exteds to prescribers i other specialities. Therefore it is recommeded that: Nurses ad midwives should be eabled to prescribe ulicesed medicatios oce they come withi their scope of practice ad urse/midwife prescribers are cogisat of best practice i the prescribig of ulicesed medicatios 1. The Departmet of Health ad Childre review all relevat medicies regulatios to eable urses ad midwives prescribe ulicesed medicatios oce they come withi their scope of practice 2. A Bord Altraais be asked to review their Practice Stadards i light of ay chages arisig from implemetatio of the above recommedatios. A Bord Altraais be asked to develop guidace for urses/midwives o the best practice for prescribig ulicesed medicatios Recommedatio III Prescribig Medicatios Outside their Terms of Licece (Off-Label Medicatios) It is evidet from the fidigs of this idepedet evaluatio that a barrier for urse ad midwife prescribers is their iability to prescribe medicatios outside their terms of licece (Off-Label Medicatios). Therefore it is recommeded that: Nurses ad midwives should be eabled to prescribe off-label medicatios oce they come withi their scope of practice ad urse/midwife prescribers are cogisat of best practice i the prescribig of medicatios outside their terms of licece 3. The Departmet of Health ad Childre review all relevat medicies regulatios to eable urses ad midwives prescribe off-label medicatios oce they come withi their scope of practice. 1 Whe reviewig this recommedatio the idepedet evaluatio would suggest that the followig should be take ito cosideratio: 1) the ulicesed medicatio is regularly used to treat patiets i the prescriber s area of practice, 2) the ulicesed medicatio to be prescribed must be agreed i advace with the prescriber s Drugs ad Therapeutics Committee, 3) it is ackowledged by the prescriber that a alterative licesed medicatio would ot be more suitable, 4) ulicesed medicatios that are ew or o cliical trail should ot ormally be prescribed by urse/midwife prescribers, 5) the patiet should be made aware that the drug beig prescribed is ulicesed. 2 Medicial Products (Cotrol of Wholesale Distributio) Regulatios 2007 (S.I. o. 538 of 2007) Medicial Products (Cotrol of Maufacture) Regulatios 2007 (S.I.) o. 539 of 2007) Medicial Products (Cotrol of Placig o the Market) Regulatios 2007 (S.I. o. 540 of 2007) Medicial Products (Licesig ad Sales) Regulatios 2007 (S.I. o. 540 of 2007) 3 Whe reviewig this recommedatio the idepedet evaluatio would suggest that the followig should be take ito cosideratio: 1) the off-label medicatio is regularly used to treat patiets i the prescriber s area of practice, 2) the off-label medicatio to be prescribed must be agreed i advace with the prescriber s Drugs ad Therapeutics Committee, 3) it is ackowledged by the prescriber that a alterative medicatio would ot be more suitable, 4) the patiet should be made aware that the drug beig prescribed is off-label. xv

18 Recommedatios (cotiued) A Bord Altraais be asked to review their Practice Stadards i light of ay chages arisig from implemetatio of the above recommedatios A Bord Altraais be asked to develop guidace for urses/midwives o the best practice for the prescribig of off-label medicatios Recommedatio IV Prescribig of Cotrolled Drugs The prescribig of cotrolled drugs by urses ad midwives with prescriptive authority is regulated by MDA Schedule 8. This was itroduced specifically to idetify the drugs ad route of admiistratio for which a schedule 2 or 3 medicatio ca be prescribed by a RNP. I its preset format Schedule 8 is ihibitig the prescribig practice of urses/midwives, especially those workig i the area of pai maagemet, due to the restrictios o the type of cotrolled drugs that they are permitted to prescribe. It is therefore recommeded that: The provisio of prescribig practice withi preregistratio educatio should be debated withi the proposed review of udergraduate ursig educatio beig udertake by the Departmet of Health ad Childre. Iovative forms of educatio should be cosidered to deliver the prescribig preparatio programme such as bleded learig, olie learig ad distace learig. Higher Educatio Istitutios providig urse/ midwife prescribig educatio programmes i the future should have access to expertise i pharmacy ad medicie. Accreditatio of prior learig is cosidered for applicats to the programme. Experieced urse/midwife prescribers should be cosidered to act as metors to cadidate prescribers. The Departmet of Health ad Childre review the relevat medicies products regulatios for Schedule 8 with a view to eablig all urses ad midwives prescribe cotrolled drugs i Part II of Schedule 8 where the drug is ormally used i a specific cliical settig ad falls withi a urse s/midwife s scope of practice Recommedatio V Educatio of Nurse/ Midwife Prescribers The idepedet evaluatio cosiders that there are three educatioal pathways for the developmet of urse/midwife prescribig: maiteace of stad-aloe prescribig programme, itegratio with post-registratio educatio ad cosideratio of prescribig practice at pre-registratio level. Therefore it is recommeded that: The curret stad aloe Certificate i Nursig (Nurse & Midwife prescribig) cotiue, remai at level 8, ad that requiremets for etry to the programme remai uchaged. The relevat modules be itegrated ito existig ad future post-registratio ursig ad midwifery programmes where prescribig is relevat to cliical practice Recommedatio VI Registratio of Nurse/ Midwife Prescribers The idepedet evaluatio has foud satisfactio with the registratio process ad therefore recommeds that the process remai uchaged. However it does recommed that: A Bord Altraais should be requested to cosider puttig a timeframe o a acceptable period betwee completio of the course ad registratio as a urse prescriber Recommedatio VII Cotiuig Professioal Developmet The idepedet evaluatio has foud that there is variability to the extet to which urse/midwife prescribers access cotiuig professioal developmet. Therefore it is recommeded that: All urse ad midwife prescribers should maitai their professioal competece i prescribig o a ogoig basis; this recommedatio will be iformed by proposed legislatio related to professioal competece i the forthcomig Nurses ad Midwives Act. xvi

19 1.2.7 Recommedatio VIII Collaborative Practice Agreemet (CPA) It is evidet from the fidigs of this idepedet evaluatio that the Collaborative Practice Agreemet has utility i the early developmet of the urse s/midwife s prescribig practice. It is also idetified that the CPA over time may add a admiistrative burde to prescribers ad Drugs ad Therapeutics Committees. Furthermore, the CPA may be a barrier to the developmet of idepedet prescribig by urses ad midwives i the future. Therefore it is recommeded that: The Collaborative Practice Agreemet remais i place as a requiremet for registratio as it establishes the cliical, maagemet ad corporate goverace arragemets withi each orgaisatio. It also officially records prescriptive authority give by a employer to the urse/midwife, thus facilitatig a cliical idemity requiremet. Oce the prescribig iitiative has bee further developed cosideratio should be give by A Bord Altraais to phasig out the requiremet for the Collaborative Practice Agreemet o a ogoig basis. I light of the above recommedatio A Bord Altraais give cosideratio to providig guidace to RNPs o establishig cliical, maagemet ad corporate goverace arragemets o prescribig practice with their health service employer. Drugs ad Therapeutics Committees review their curret arragemets for assessig Collaborative Practice Agreemets with a view to expeditig the process for urse/midwife prescribers. I light of the above recommedatios the health service employer should assure itself that it has established cliical, maagemet ad corporate goverace arragemets o prescribig practice with each urse/midwife prescriber Recommedatio IX Prescribig Practice The idepedet evaluatio foud that overall urse/ midwife prescribig was safe ad efficiet however there are a umber of areas i which prescribig practice ca be improved. Therefore it is recommeded that: The health service provider put ito place the appropriate arragemets to esure that prescribig practices are cogruet with HSE atioal policies 4 for urse ad midwife prescribig icludig security of prescriptio pads, recommedatios o Photostat copies of patiet cosultatios, ad legibility of prescriptios ad documetatio. The idepedet evaluatio team cosiders that cosideratio should be give to the itroductio of electroic prescribig system. This system would sigificatly reduce duplicatio of documetatio while improvig clarity ad commuicatio betwee multidiscipliary teams. A Bord Altraais, i cojuctio with health service providers, should review Practice Stadards with a view to outliig the criteria that should be recorded o patiet/service-user case otes ad medicatio admiistratio records followig a prescribig cosultatio by a RNP. These stadards, oce agreed, should be reflected i prescribig educatio preparatio programmes. Health Service Providers should cotiue to develop a culture of critical review ad multidiscipliary audit to esure a good practice develops ad to promote a culture of mutual respect ad learig amog health care professioals Recommedatio X Future Developmets The idepedet evaluatio further recommeds that: A further evaluatio of the urse/midwife prescribig iitiative is udertake two years followig the publicatio of this report. The ratioale beig that a critical mass of prescribers will be i place ad there will have bee a roll out of the iitiative i a umber of diverse cliical settigs. The implemetatio framework developed, desiged ad rolled out by the HSE provides a model of best practice for the implemetatio of prescribig for health service providers exteral to the Executive. The Nurse ad Midwife Prescribig Data Collectio System for moitorig urse ad midwife prescribig should cotiue. 4 Health Service Executive (2009) Natioal Policy for Nurse ad Midwife Medicial Product Prescribig i Natioal Hospitals Office. HSE. xvii

20 1