Transcript No Slide Title

The Impact of Nurse and
Midwife Medicinal
Product Prescribing
Dr. Siobhan O’Halloran
18 June, 2009
Irish Pharmaceutical Healthcare Association
Confidence
Easy of Access
Staff Pride
To enable people live healthier and more fulfilled lives
Function
The main priority of The Office
…is to provide leadership, support excellence
and build capacity in nursing and midwifery in
order to enhance patient care and service delivery
Key focus areas:
―practice development
―education and training
―governance, quality and standards
―capacity building
―leadership
Operational Framework
Health of the Irish Population
― 4.42 million people in Ireland
― 73,815 babies born in 2008 (5% increase on 2007)
― Life expectancy Men =76.8 Women = 81.6 years
― 88% Children receive MMR vaccine by 2nd birthday
― 29% adults smoke, 39% overweight, 23% obese, 22%
report physical inactivity, 28% consume six or more
drinks at least once a week
― 28% attendances in ED are alcohol related
― 80% of GP visits and 60% of hospital bed days related to
chronic illness and associated complications
― Over 400 outbreaks of infectious diseases in 2008
Source: Health Service Executive (2008) Annual Report, available https:www.hse.ie
Entry to the Profession
• Pre-registration (school leaver / mature applicant)
Direct entry
BSc in Nursing/
Midwifery
4/4.5 years
Honours Degree
Commenced ’02
860 Places - General Nursing RGN
290 Places - Intellectual Disability Nursing RNID
180 Places - Psychiatric Nursing RPN
100 Places - Children's General Nursing (integ) RCN
140 Places - Midwifery RM
• Post-registration (for RGN, RNID, RPN, RCNs)
Further
Education
Midwifery RM
Post Grad
Diploma / MSc
Nurse Tutor RNP
Psychiatric RPN
Children's RCN
77 Places - Public Health Nursing RPHN
160 Places - Nurse Prescriber RNP
Role Expansion
―Nurse Led Clinics
―Intravenous Cannulation
―Venepuncture
―Nurse Led Discharge
―Nurse/Midwife Medicinal
Product Prescribing
―Nurse Prescribing - Medical
Ionisation Radiation
―Forensic Examination
Source: Office of the Nursing Services Director, HSE HR Directorate www.hse.ie
Employment in the Public Health Service
National
Hospitals
Office
Corporate
Medical/ Dental
Nursing
Health and Social Care
Professionals
Management/ Admin
General Support Staff
Other Patient and Client Care
Total
Primary,
Community
and
Continuing
Care
Population
Health
Total
36
6,071
109
1,894
8,109
07%
145
20,752
19
17,193
38,108
34%
37
6,318
57
9,568
15,980
14%
2,686
8,153
307
6,821
17,967
16%
454
7,078
2
5,096
12,631
11%
12
4,774
46
13,399
18,230
17%
3,369
53,146
540
53,971
111,025
Source: Health Services Personnel Census, December 2008
Working hours for nurses/midwives ↓39 hours per week to 37.5 in 2008
Commission on Nursing Hours currently examining feasibility of further ↓ to 35 hours per week
Nurse and Midwife
Medicinal Product Prescribing
Approach to Implementation
 National Steering Group
 Set up by Minister for Health & Children
― November 2006
 Chair
― Dr Siobhan O’Halloran, Nursing Services Director
 Thirty Three Members
― key stakeholders: healthcare regulatory and professional
bodies, clinical practitioners, health service managers,
education providers, insurers and government bodies
 Terms of Reference
― Two year time frame (Nov’06 – Dec ’07)
Origin of Prescriptive Authority
Website: www.hse.ie
Primary Legislation
 Provisions for nurses & midwives to prescribe
 Provides for power to regulate for prescribing
 Section 16 – Key content
Accessible at: www.oireachtas.ie
Medicinal Products Prescribing
 Dual Framework
 Legislation
― Irish Medicines Board
(Miscellaneous Provisions) Act
2006. Commencement Order 2007
and 2009
― Misuse of Drugs (Amendment)
Regulations 2007
― Medicinal Products (Prescription
and Control of Supply)
(Amendment) Regulations 2007
 Professional Regulation
― Nurses Rules 2007
 All nurses and midwives
employed by a Health
Service Provider
 All prescription drugs
 Schedule 4 & 5 unrestricted
 Schedule 2 & 3 (Controlled
Drugs) restricted
 Drugs must normally be
used in the setting
 Employer can set criteria
 RNP must write PIN on
every prescription
Commitment to Review in 2 years
Prescribing
Framework for the
Practice of Nurses
& Midwives
Service
Patient Need
Service Demand
& Requirements
Regulatory Body
Nurses Rules 2007
Education / Standards
Decision Making Framework
Scope of Practice & Competency
Collaborative Practice Agreement (CPA)
Registration
Legislative Provision
Legislative Authority (Act & Regulations)
Procedural requirements
Schedule 8
RNP may prescribe within Schedules 2 & 3
Drugs for pain relief in hospital
 morphine sulphate (oral, IV, IM), codeine phosphate (oral)
Drugs for palliative care
 morphine sulphate, hydromorphine, oxycodone (oral,
subcutaneous), buprenorphine (transdermal) fentanyl
(transmucosal, transdermal) methylphedidiate and codeine
phosphate (oral)
Drugs for purposes of midwifery
 pethidine (IM)
Drugs for neonatal care in hospital
 morphine sulphate (oral, IV, IM), fentanyl (IV)
Provision of Professional Guidance
for Practice & Clinical Governance
Education Requirements and Standards
Decision-Making Framework
Practice Standards
Collaborative Practice
Agreement
Practice Standards
1
Prescription writing
2
Prescribing for self,
family & significant others
3
Repeat prescribing
7 Influence of outside interests
4
Prescribing of unlicensed
medications
8 Communication & documentation
5
6 Separation of responsibilities for
prescribing, dispensing and
supplying
9 Continuing professional
Prescribing by verbal, telephone, development & competency
email or fax
Accessible at: www.nursingboard.ie
Step x Step Guide
Education Programme Places
Certificate in Nursing (Nurse / Midwife Prescribing)
(Minor Award Level 8)
UCC
RCSI
Total
April 07
28
25
53
Oct O7
18
34
52
Feb/April 08
12
34
46
Oct 08
21
55
76
Jan/April 09
22
47
69
Total
101
195
295
Entry Requirements
Employment
 Voluntary and statutory services of the HSE
Name on Division of the Register
 General, Psychiatric, Children’s, Intellectual Disability,
 Midwife or Public Health Nurse
Site Requirements
 Support from employer to undertake the programme
 Nomination and confirmation of a designated medical practitioner mentor
Experience
 3 years recent post-registration clinical experience (within the past 5)
 With equivalent of 1 year full-time experience in specific area of practice
Technical Requirements
 Competencies recognised at Level 8 (NQAI framework)
 Evidence of further education
 Possess a competent level of information technology literacy
http:www//hse.ie/eng/About_the_HSE/Nursing_Services/
Grade of Candidates/RNPs
Numbers of RNP/ Candidates by Grade
CN/MS
Number of
Candidate/RNPs
80
SN/M
60
CNM/CMM2
ANP/AMP
40
CNM1/CMM1
CNM3/CMM3
20
PHN
0
CMHN
Grade
ADON/M
Education Programmes 2009
 Royal College of Surgeons in Ireland
School of Nursing
― Commenced: 20th April 2009
 University College Cork
Catherine McAuley School of Nursing
― Commenced: 22nd January 2009
Sixth Education Programme
To commence: 12 October 2009
Closing date: 3 July 2009
Support Structure
 Prescribing Site Coordinator (link person
within each Health Service Provider)
 Clinical Mentor (Medical Consultant / GP)
for duration of education programme
 Collaborating Medical Practitioners for
ongoing support
 Drugs and Therapeutics Committee
 Nurse Prescribing Policy
HSE Support for Organisational Preparation
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Guiding Framework for the Implementation of Nurse and Midwife Prescribing
Other publications – Audit, Monitoring, Application Guidelines etc
Prescribing Site Coordinators Groups
Course Fees funded directly by HSE
National Policy Template / Check List
Sample Terms of Reference for
Drugs and Therapeutics Committees
Advice on development of Prescription Pads
Clinical Indemnity – State Claims Agency
Access to GMS and other schemes
On going communication
― Irish RNP eNetwork
― Irish PSC eNetwork
― Media (RTE), Newsletters (Health Matters Features), Professional Journals,
Change Hub etc
Patient Information Leaflet
Nurse and Midwife Prescribing Data Collection System
Independent External Evaluation
Developments
Acute Services
― High Tech Drugs (HTD)
― Long Term Illness Scheme (LTI)
― Health (Amendment) Act 1996 (HAA)
― Drugs Payment Scheme (DPS)
― Emergency Supplies on a Hospital
Prescription for Medical Care Patient
Community Services
― Long Term Illness Scheme (LTI)
― Health (Amendment) Act 1996 (HAA)
― Drugs Payment Scheme (DPS)
― General Medical Services Scheme
Collaborative Practice Agreement (CPA)
 Principles of: professional accountability,
responsibility , competence and clinical
governance underpin the CPA
 The CPA details the lines of Communication
 established between RNP and the Medical
Practitioner regarding the care of their patients
and
 agreed by the employer
 Defines the parameters of the RNPs scope of
practice
 Outlines the parameters of the RNPs
prescribing authority
Accessible at: www.nursingboard.ie
Collaborative Practice Agreement (CPA)
 Is a prerequisite to Registration with An Bord Altranais
 Official Collaborative Practice Agreement Form Plus
― Attachment A: a general description of the practice setting including
population and conditions for which the RNP has responsibility
― Attachment B: a listing of specific medications (generic name) and/ or
categories of medications the RNP is authorised to prescribe
― Attachment C: a description of the conditions, if any, the health service
provider/employer has placed on the RNP and an outline of the
requirement for review and audit of RNP perscriptive practices
 Signed by:
― Registered Nurse Prescriber
― Collaborating Medical Practitioner (s)
― Authorised representative of health service employer
 Annual review and approval of:
― Employer and medical practitioner working with RNP
Accessible at: www.nursingboard.ie
Role of the
Drugs and Therapeutics Committee
 Multidisciplinary Group
 Advise on the proposed list of drugs, for
example
― Generic form of medicinal product
― Authorised product
― Appropriate to clinical setting and scope of practice of RNP
― In keeping with the organisations formulary and legislative
requirements
Clinical Indemnity Scheme Cover
All Employees of the voluntary and statutory
services of the HSE including:
 Registered Nurse/Midwife Prescriber “carrying out
prescribing as part of the provision of medical
services…..with the knowledge and consent of the
health service provider”
 Registered Medical Practitioners acting as a mentor
(“fully covered”)
 “Indemnify a registered medical practitioner, who has
signed a collaborative practice agreement…for a
nurse/midwife prescriptive authority…..”
Sample Report
25 Jan 2008 – 31 May 2009
Prescription Episodes:
6,909
Unique Patients:
5,607
Involving:
10,008 individual medicinal
products
Audit of Nurse and Midwife Prescribing
Implementation – Statistics
June 2009
Organisations = 93 (PCCC 54 and NHO 39)
Clinical Areas = 64
Students = 295
Preparing for registration = 48
RNP = 83
HSE West
Sites with RNPs = 34
HSE North East
HSE Dublin Mid
Leinster
Two year target = 200
HSE South
Progress in the National Introduction of
Nurse Prescribing
RNP Dec 07 - June 09
90
80
84 RNPs
Number of RNPs
70
60
50
40
NHO = 72
30
20
PCCC = 12
10
0
Dec- Jan07
08
Feb- Mar- Apr- May - Jun- Jul-08 Aug08
08
08
08
08
08
Sep08
Month
Oct- Nov - Dec- Jan08
08
08
09
Feb- Mar09
09
Apr- May - Jun09
09
09
RNP Verification
Verification
Independent External Evaluation
Independent External Evaluation for Nurse and Midwife Prescribing
E-tenders public procurement website: www.etenders.gov.ie.
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Contract awarded to a research team for University College Dublin
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Commenced 5 January 2009 to finish end June 2009
To evaluate from a service perspective having regard to the following:
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relevant legislation and regulations
professional regulation and guidance
educational preparation, including selection processes
service implementation including factors facilitating and inhibiting
prescribing opportunities
monitoring processes
auditing prescribing process, patterns, practices and
compliance
communication
value for money
current and potential outcomes of nurse and midwife prescribing in
terms of benefits, safety and satisfaction
take into account the views of key stakeholders
1.
The research is a collaborative approach
incorporating:
I. UCD School of Nursing, Midwifery & Health
Systems.
II. UCD School of Biomolecular and Biomedical
Science.
III. UCD School of Medicine and Medical
Science.
RNP Identified Positive Outcomes:
 National standardised implementation framework (underpinned by legislation and
regulation)
 Evidence based standards - nationally adopted
 Collaboration between medical practitioners nurse/midwife prescribers and
pharmacists re appropriate prescribing (CPA)
 Only authorised drugs are prescribed by RNP
 Generic names for prescribing
 Every organisation must have a formal approved nurse prescribing policy (clarity on
processes - risk management, incident, serious adverse events reporting)
 Provided impetus to establish or re-establish Drugs and Therapeutics Committees
 Each RNPs practice is monitored and audited using the Nurse and Midwife
Prescribing Data Collection System
 Introduction has resulted in 93 organisations across the country examining practices
for example, safe management of prescription pads
 Close relationship with patients – RNPs may have more time for patient education
 Ongoing relationship with patients, additional ability to identify errors and
confidence to address issues with other prescribers