Molly Courtenay

Independent and supplementary prescribing: an essential guide

Preface 1. Non-medical prescribing: an overview Molly Courtenay and Matt Griffiths 2. Non-medical prescribing in a multidisciplinary team context Barbara Stuttle 3. Consultation skills and decision making Anne Baird 4. Legal aspects of independent and supplementary prescribing Mark Gagan 5. Ethical issues in independent and supplementary prescribing John Adams 6. Psychology and sociology of prescribing Tom Walley and Robin Williams 7. Applied pharmacology Michele Cossey 8. Monitoring skills: a. Asthma Trisha Weller b. Coronary heart disease Paul Warburton c. Diabetes Jill Hill 9. Promoting concordance in prescribing interactions Sue Latter 10. Evidence-based prescribing Trudy Granby and Steve Chapman 11. Extended/supplementary prescribing: a public health perspective Sarah OBrien 12. Calculation skills Alison Eggleton 13. Prescribing in practice Polly Buchanan 14. Medication safety Gillian Cavell Index.

Improving inflammatory arthritis management through tighter monitoring of patients and the use of innovative electronic tools

Treating to target by monitoring disease activity and adjusting therapy to attain remission or low disease activity has been shown to lead to improved outcomes in chronic rheumatic diseases such as rheumatoid arthritis and spondyloarthritis. Patient-reported outcomes, used in conjunction with clinical measures, add an important perspective of disease activity as perceived by the patient. Several validated PROs are available for inflammatory arthritis, and advances in electronic patient monitoring tools are helping patients with chronic diseases to self-monitor and assess their symptoms and health. Frequent patient monitoring could potentially lead to the early identification of disease flares or adverse events, early intervention for patients who may require treatment adaptation, and possibly reduced appointment frequency for those with stable disease. A literature search was conducted to evaluate the potential role of patient self-monitoring and innovative monitoring of tools in optimising disease control in inflammatory arthritis. Experience from the treatment of congestive heart failure, diabetes and hypertension shows improved outcomes with remote electronic self-monitoring by patients. In inflammatory arthritis, electronic self-monitoring has been shown to be feasible in patients despite manual disability and to be acceptable to older patients. Patients self-assessment of disease activity using such methods correlates well with disease activity assessed by rheumatologists. This review also describes several remote monitoring tools that are being developed and used in inflammatory arthritis, offering the potential to improve disease management and reduce pressure on specialists.

Antibiotics for acute respiratory tract infections: a mixed-methods study of patient experiences of non-medical prescriber management

Objective To (1) explore patients expectations and experiences of nurse and pharmacist non-medical prescriber-led management of respiratory tract infections (RTIs), (2) examine whether patient expectations for antibiotics affect the likelihood of receiving them and (3) understand factors influencing patient satisfaction with RTI consultations. Design Mixed methods. Setting Primary care. Participants Questionnaires from 120 patients and follow-up interviews with 22 patients and 16 nurse and pharmacist non-medical prescribers (NMPs). Results Patients had multiple expectations of their consultation with 43% expecting to be prescribed an antibiotic. There was alignment between self-reported patient expectations and those perceived by NMPs. Patient expectations for non-antibiotic strategies, such as education to promote self-management, were associated with receipt of those strategies, whereas patient expectations for an antibiotic were not associated with receipt of these medications. ‘Patient-centred’ management strategies (including reassurance and providing information) were received by 86.7% of patients. Regardless of patients expectations or the management strategy employed, high levels of satisfaction were reported for all aspects of the consultation. Taking concerns seriously, conducting a physical examination, communicating the treatment plan, explaining treatment decisions and lack of time restrictions were each reported to contribute to patient satisfaction. Conclusions NMPs demonstrate an understanding of patient expectations of RTI consultations and use a range of non-antibiotic management strategies, particularly those resembling a patient-centred approach. Overall, patients expectations were met and prescribers were not unduly influenced by patient expectations for an antibiotic. Patients were satisfied with the consultation, indicating that strategies used by NMPs were acceptable. However, the lower levels of satisfaction among patients who expected but did not receive an antibiotic indicates that although NMPs appear to have strategies for managing RTI consultations, there is still scope for improvement and these prescribers are therefore an important group to involve in antimicrobial stewardship.

One Health: An opportunity for an interprofessional approach to healthcare

Abstract One Health has been viewed as the collaborative effort between professions and disciplines working locally, nationally, and globally to attain optimal health for people, animals, and the environment. For One Health principles to be operationalised, interprofessional education and interprofessional collaborative practice are essential. However, interprofessional initiatives between the human health professions and veterinary medicine focus primarily on patient care in the human health setting. The purpose of this report is to describe two models of collaboration between human and veterinary medicine that have been designed to address human and animal health challenges in practice. Initiatives that involve this cooperation are providing access to affordable and clean drinking water. Implications linked to these initiatives are explored in relation to the need for an interprofessional approach to attain optimal health for people, animals, and the environment.

Patterns of dispensed non-medical prescriber prescriptions for antibiotics in primary care across England: a retrospective analysis

ObjectivesnTo describe the patterns of dispensed non-medical prescriber (NMP) prescriptions for antibiotics in primary care across England between 2011 and 2015.nnnMethodsnA retrospective analysis of dispensed antibiotic prescriptions, written by NMPs and medical prescribers between 2011 and 2015 in primary care in England, obtained from the National Health Service Business Services Authority.nnnResultsnBetween 2011 and 2015, the number of NMPs (mainly nurses but also pharmacists and small numbers of allied health professionals) in England, who have independent prescribing capability, has risen by over one-third to nearly 30000. Most of these prescribers provide a broad range of services in primary care. The rate of dispensed NMP prescriptions for antibiotics over this period has increased, as has the percentage of all primary care antibiotics dispensed that were prescribed by NMPs, which is currently nearly 8%. The most commonly dispensed NMP antibiotic prescriptions were penicillin, sulphonamides, trimethoprim, macrolides, tetracyclines and nitrofurantoin.nnnConclusionsnIncreasing numbers of NMPs are working in primary care in England and managing infections. Antibiotics prescribed by this group align with surveillance reports of antibiotic use in primary care. With the numbers of NMPs being set to rise further, they form an important group to involve in antimicrobial stewardship efforts.

Overview of the uptake and implementation of non-medical prescribing in Wales: a national survey

Objectives To identify (1) the non-medical healthcare professionals in Wales qualified to prescribe medicines (including job title, employer, where the prescribing qualification is used, care setting and service provided); (2) the mode of prescribing used by these healthcare professionals, the frequency with which medicines are prescribed and the different ways in which the prescribing qualification is used; and (3) the safety and clinical governance systems within which these healthcare professionals practise. Design National questionnaire survey. Setting All three National Health Service (NHS) Trusts and seven Health Boards (HB) in Wales. Participants Non-medical prescribers. Results 379 (63%) participants responded to the survey. Most of these prescribers (41.1%) were specialist nurses who work in a variety of healthcare settings (primarily in secondary care) within each HB/NHS Trust, and regularly use independent prescribing to prescribe for a broad range of conditions. Nearly a quarter of the sample (22%) reported that prior to undertaking the prescribing programme, they had completed master’s level specialist training and 65.5% had 5u2009years qualified experience. Over half (55.8%) reported that there were plans to increase non-medical prescriber numbers within the team in which they worked. Only 7.1% reported they did not prescribe and the median number of items prescribed per week was between 21 and 30. Nearly all (87.8%) of the sample reported that they perceived prescribing to have ensured better use of their skills and 91.5% indicated that they believed it had improved the quality of care they were able to provide. Conclusion Non-medical prescribing has been implemented across the whole of Wales; however, its uptake within HBs and NHS Trusts has been inconsistent, and it has not been considered across all services, particularly those in primary care. Opportunities therefore exist to share learning across organisations.

A comparison of prescribing and non-prescribing nurses in the management of people with diabetes

AIMnThe aim of this study were to compare nurse prescribers and non-prescribers managing people with diabetes in general practice regarding: (a) patient characteristics; (b) activities and processes of care; (c) patient outcomes (self-management, clinical indicators, satisfaction) and (d) resource implications and costs.nnnBACKGROUNDnOver 28,000 nurses in the UK can prescribe the same medicines as doctors provided that it is in their level of experience and competence. Over 30%, mostly in general practice, prescribe medicines for patients with diabetes.nnnDESIGNnA comparative case study.nnnMETHODnNurses managing care of people with Type 2 diabetes were recruited in twelve general practices in England; six could prescribe, six could not. Patients, recruited by nurses, were followed up for 6xa0months (2011-2012).nnnRESULTSnThe patient sample comprised 131 in prescriber sites, 83 in non-prescriber sites. Patients of prescribers had been diagnosed and cared for by the nurse longer than those of non-prescribers. There were no differences in reported self-care activities or HbA1c test results between the patients of prescribers and non-prescribers. Mean HbA1c decreased significantly in both groups over 6xa0months. Patients of prescribers were more satisfied. Consultation duration was longer for prescribers (by average of 7·7xa0minutes). Non-prescribing nurses sought support from other healthcare professionals more frequently. Most prescribing nurses were on a higher salary band than non-prescribers.nnnCONCLUSIONnClinical outcomes of patients managed by prescribing and non-prescribing diabetes nurses are similar. Prescribing nurses had longer relationships with their patients and longer consultations, possibly contributing to higher satisfaction with care. Employment costs of prescribing nurses are potentially higher.

Antibiotic prescribing in primary care: The need for interprofessional collaboration

Abstract Patients with self-limiting respiratory tract infections (RTIs) are frequently seen in general practice. Although antibiotics are ineffective for these conditions, they are often prescribed by general practitioners (GPs), and perceived patient expectations for an antibiotic plays an important role in the decision to prescribe one. Superfluous use of antibiotics contributes to antimicrobial resistance. High numbers of nurse prescribers work alongside GPs and these prescribers see education and self-management advice as central to the care of these patients. Multi-faceted interventions, designed to reduce antibiotic prescribing, only exist for GPs. Such interventions should foster interprofessional collaboration and, as such, consider the needs and experiences of the different prescribers, and the views of patients. This paper outlines a research study in which a questionnaire will be distributed to patients who consult with a nurse prescriber to see whether their expectations influence their satisfaction with the consultation outcome. Findings will guide the development of an interprofessional intervention designed to promote collaborative practice and appropriate and responsible antibiotic prescribing in primary care.

Independent and Supplementary Prescribing: Non-medical prescribing: an overview

In 1986, recommendations were made for nurses to take on the role of prescribing. The Cumberlege report, Neighbourhood nursing: a focus for care (Department of Health and Social Security (DHSS) 1986), examined the care given to clients in their homes by district nurses (DNs) and health visitors (HVs). It was identified that some very complicated procedures had arisen around prescribing in the community and that nurses were wasting their time requesting prescriptions from the general practitioner (GP) for such items as wound dressings and ointments. The report suggested that patient care could be improved and resources used more effectively if community nurses were able to prescribe as part of their everyday nursing practice, from a limited list of items and simple agents agreed by the DHSS. Following the publication of this report, the recommendations for prescribing and its implications were examined. An advisory group was set up by the Department of Health (DoH) to examine nurse prescribing (DoH 1989). Dr June Crown was the Chair of this group. The following is taken from the Crown report: Nurses in the community take a central role in caring for patients in their homes. Nurses are not, however, able to write prescriptions for the products that are needed for patient care, even when the nurse is effectively taking professional responsibility for some aspects of the management of the patient. However experienced or highly skilled in their own areas of practice, nurses must ask a doctor to write a prescription. It is well known that in practice a doctor often rubber stamps a prescribing decision taken by a nurse. […]

Medication Safety: Introduction to medication errors and medication safety

A medication safety incident is defined by the National Patient Safety Agency (NPSA) as: ‘any unintended or unexpected incident which could have or did lead to harm for one or more patients’ (NPSA, 2007:9). These incidents can occur at each stage of the process involved in the delivery of medicines to patients, i.e. prescribing (including transcribing or physician ordering), dispensing, preparation, administering and monitoring (NPSA, 2007). Medication incidents have been reported as accounting for 10%–20% of all Adverse Events (AE) (Department of Health (DoH), 2004), i.e. an event that causes an unintended injury to a patient that either prolongs hospitalization or produces disability (Karson & Bates, 1999). The impact of medication safety incidents on patient outcomes includes increased length of stay, disability and mortality (Vincent et al., 2001). Across the UK, about two and a half million medicines are prescribed across hospitals and the community every day (DoH, 2004) and an indicator of quality, adopted to demonstrate medication safety, is the incidence of medication errors (DoH, 2004). The Government has committed to reducing the incidents of medication errors in prescribed drugs by 40% (DoH, 2004). Between January 2005 and June 2006, 60 000 medication incidents were reported to the NPSA via the National Reporting and Learning System (NRLS) (NPSA, 2007). Although most medicine-related activity is carried out in the community, over 80% of the incidents reported to the NPSA were from the hospital setting. The majority of these incidents (over 80%) did not result in harm. Wrong dose, strength or frequency of medicine, omitted medicine and wrong medicine were errors that occurred most frequently and accounted for nearly 60% of all incidents reported. Ninety-two out of the 60 000 medication incidents reported to the NPSA resulted in severe harm or death and arose from errors involving the administration and prescribing of medicines. Medicines most frequently associated with these incidents included opioids, anticoagulants, anaesthetics, insulin, antibiotics, chemotherapy, anti-psychotics and infusion fluids. The two groups of patients associated with medication errors, and highlighted in the NPSA report, included patients with known allergies being given medicines to which they were allergic (notably antibiotics), and errors involving specific medicines and dose calculations in children up to 4 years old. Other important areas highlighted by the report included the high number of injectable medicines resulting in death and severe harm; risks associated with care transfer and the importance of accurate documentation; the availability and supply of certain medicines at the point they are required; medicines given outside a medicines ward round, or to those patients with specific needs. Chapter