Independent Prescribing and the Clinical Research Nurse Dr Kathryn Jones Deputy Director of Nursing For the Research Nurse Professional Development Meeting: Where do we go from here?

Independent prescribing = new role/ way of working Professional context = Modernising Nursing Careers The Modernising Nursing Careers Programme is working to equip nurses with the skills and capabilities for their roles by: creating a more flexible and competent workforce updating career pathways and choices for nurses better preparing nurses to lead in a changed system updating the image of the nurse (pg 19) DH (2008) A high quality workforce Referring to DH (2006) Modernising Nursing Careers

Some of the relevant MNC policy/ literature… DH (2008) High Quality Care for all DH (2008) Framing the Nursing and Midwifery Contribution Kings College London (2008) Nurses in society: starting the debate Kings College London (2008) State of the art metrics for nursing: a rapid appraisal Kings Fund (2008) Seeing the person in the patient Prime Ministers Commission (2010) Front line care

Provider Development Market Development Education Planning (Supply) Contracting Quality & Performance Management Workforce Planning Education Planning (Demand) Regional fit: Workforce planning/education commissioning cycle (NHS London)

What is nurse prescribing? A recognised role for district nurses and health visitors since early 1990s Prescribing extended to nurses in any health economy in 2002 Non-medical prescribing introduced for other professional groups in 2003 beginning with pharmacists Also chiropodists, podiatrists, radiographers and optometrists from 2005

What is its intention? Primarily for patient benefit by providing quicker and more efficient access to medicines with better use of staff skills… DH (2004) Extending independent nurse prescribing within the NHS in England, DH (2006) Medicines matter, DH (2006) Improving patients access to medicines…

My study: background/context (Nov 2004) Little known about nurse prescribing in acute care Professional literature that focused on the implementation of nurse prescribing roles in primary care settings Existing studies that were mainly descriptive although they used a variety of methods Policy imperatives that required organisations to modernise and to explore new roles and ways of working

Aim: to evaluate the implementation of nurse prescribing in an acute hospital Trust With specific objectives to: describe the background and intended purpose of nurse prescribing roles explore the experiences of nurse prescribers and their role networks test the null hypotheses that there were no differences between the roles of medical and nurse prescriber within the study site

Data collection: multiple methods Semi-structured interviews with nurse prescribers (n=3), their colleagues (n=6), and Trust strategic leads (n=9)- July 2005 to September 2006 Non-participant observation (n=52 patient consultations) using a structured proforma- Nov 2005 to Jan 2006 A patient survey (n=121) using a questionnaire developed to test the null hypotheses including length of consultation, beliefs about medicines and patient satisfaction with the information received about medicines (BMQ and SIMS: Horne 1999, 2000, Horne et al 1999, 2001)- November 2005 to April 2006

Findings from the interview dataset Overall nurse prescribing was viewed positively Patient benefits: timely treatment, faster access to professionals/medicines, increased satisfaction, better understanding of medicines Staff benefits: opportunity to use skills differently to improve teamwork/ share workload Prescribing roles a natural progression for the nurses and teams involved- nurses felt confident and competent Doctors, nurse managers and peers were key supports Doctors held positive views about nurse prescribing but impact on their workload was unclear

Findings from the observation dataset No differences were found in the dataset that related to: the prescribers approach to their patients the ways in which they managed patients medicines the ways in which they managed follow-up consultations the number of patients who received a prescription the number/ types of medicines prescribed for the patient the frequency of prescribing by the prescriber This may be explained by use of team protocols Patients with longest consultation times saw a Dr

Findings from the patient survey dataset No differences were found in the data set that related to: the patients confidence and trust in the prescriber the patients beliefs about their medicines [ethnicity] BUT a significant difference was found relating to the patients satisfaction with the information received about their medicine. Patients who had consulted a nurse reported higher satisfaction ratings than those who had consulted a doctor (χ² df. p<0.001)

Drivers, resistors and enablers Shared vision Local champions Action learning Team, peer and buddy support Jones K, Edwards M While A (2011) Nurse prescribing roles in acute care: an evaluative case study. Journal of Advanced Nursing, 67, 1,

Significance within culture of improvement? Equity and excellence: liberating the NHS (DH July 2010) Putting patients and the public first Improving healthcare outcomes Autonomy, accountability and democratic legitimacy Cutting bureaucracy and improving efficiency Liberating the NHS: developing the healthcare workforce (DH Dec 10) Robust workforce planning A responsive and flexible workforce Continuous improvement in quality of education/ training Transparency and VFM Equitable access for a diverse workforce

Whats the impact on team workload…. Substituting nurses into more traditional medical roles may not release overall workforce capacity. This is because substituting one kind of worker for another kind of worker can coincide with increasing the workload of both types of worker. Particularly during a time of expanding activity (Buchan and Calman 2004)

Value-added? Systematic reviews of the research literature have accounted no appreciable differences in the care delivered by doctors and by nurses, but they report that nurses spend longer with patients (Horrocks et al 2002, Buchan and Calman 2004, Laurant et al 2005)

Cost comparisons? Laurant et al (2005) although the quality of care was similar for patients seen by nurses or doctors, and there were no appreciable differences found in their health outcomes, the impact of the nurses roles on doctors workload was unclear Buchan and Calman (2005) from a review of the literature regarding health workforce skill-mix changes, reported that nurse-led services were variously identified to be cost neutral, higher cost or lower cost than doctor- led services

Fit with advanced level nursing?

Provider Development Market Development Education Planning (Supply) Contracting Quality & Performance Management Workforce Planning Education Planning (Demand) Key: workforce planning and education commissioning cycle (NHS London)