Download Standing Orders in Primary Care Research Portfolio MMSc

Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Title :
Standing Orders In New Zealand Primary Care.
Research Portfolio.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Research Portfolio
Acknowledgements :
Dr Ross Lawrenson.
For personal support and mentoring.
Prof Des Gorman Auckland University School of Medicine and the New Zealand
Institute for Rural Health for affording me the opportunity to undertake this research
through the position of part time senior lecturer in rural health.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Contents:
Page 4 …………..Portfolio Abstract.
Page 5 …………..Part 1 – Systematic Literature Review.
Page 48 ……… Part 2 - Research Projects.
Page 49 ………….Project 1 – Practice Review :
Use of standing orders in a single rural practice.
Page 59………..…Project 2 – Purposive Questionnaire :
Barriers and advantages to the use of standing orders in primary care.
Page 84…………..Conclusion.
Page 85…………..Appendix 1 – papers identified in literature review.
Page 111…………Appendix 2 – questionnaire development.
Page 114 ………. References.
Attachment 1 – Copy of literature review paper as published.
Attachment 2 - Copy of Presentation to the 2007 Royal New Zealand College of
General Practitioners Conference (similar presentations made to the Rural GP
Network Conference 2008 and Practice Nurses Conference 2008.)
Research Portfolio Author Responsibilities.
Dr J Scott-Jones has been the lead author of research presented in this portfolio, he
has been primarily responsible for the design, implementation, interpretation and
presentation of the work presented.
The role of co-author Professor Ross Lawrenson was advisory and providing proof
reading and suggestions for stylistic changes, and for the standing order use in a rural
practice report the role of Practice Nurses at the surgery was to be involved in the
collection of data.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
PORTFOLIO ABSTRACT
A standing order is defined as a written protocol agreed between a medical
practitioner or dentist and another health professional which includes the provision of
a medication under defined circumstances.[1]
The 2002 Medicines (Standing Order) Regulations were passed to allow health
professionals who are not registered to prescribe, to administer medications under
specific written circumstances with the supervision of a registered provider.
A review of the available literature regarding randomised controlled trials and
standing orders use in primary care is presented and shows a limited amount of
research available, with no New Zealand specific research, but what is available
indicates standing orders are a safe way of providing care, acceptable to patients, and
come with a variable financial cost to health care systems.
An audit of standing order care in one rural General practice is presented which shows
the extent and range of standing order use in this single clinic setting.
A research project is presented which explores the perceived barriers and advantages
to the use of standing orders from a range of rural and urban practices across New
Zealand and the range of standing orders used in these clinics.
Increased use of standing orders may be part of the response to increasing pressure on
the workforce in New Zealand, and be an enabling process to extend the scope of
nursing practice in primary care. Developing a nationally acceptable process for the
establishment of standing orders based on best practice guidelines and protocol driven
care may address some of the barriers to the further progression of the use of standing
orders in primary care.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Part 1
Systematic review
(Published in New Zealand Family Physician April 2008 “Doctors and Nurses:
Standing Orders in Primary Care - a literature review “ [2] )
ABSTRACT :
Background:
Standing orders are a useful tool to extend the scope of primary health care team
workers and increase access to services for patients. They have been used in
secondary services and in isolated rural communities since legislation was passed
allowing their development in New Zealand in 2002[1].
Extending standing order use is one response that teams can use to deal with
workforce pressure, but there is limited evidence available regarding the safety,
efficacy, or cost benefit of using standing orders in primary care.
Aim:
The aim of this study was to review the published literature regarding the use of
standing orders in primary care to compare clinical outcomes, cost comparisons and
patient satisfaction between usual care and standing order care.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Methods:
A systematic literature review was conducted by the author using on line databases
available through the Auckland Medical School Library.
Papers included in the study were randomized controlled trials comparing usual GP
care with care provided by nurses utilizing standing orders in primary care settings.
Results:
7 papers were identified that had some relevance, a meta-analysis was not attempted
because of the lack of homogeneity in the studies found.
3 papers referred to the use of protocol driven care and although small these studies
indicate that nurses can treat a variety of conditions using protocols developed within
a practice effectively and safely. 2 papers explore the effect of extending the nursing
role to enable them to see patients presenting for a ‘same day’ consultation, they show
that nurses can provide care equivalent to that of a GP, but that nurse consultations are
longer and result in increased referral rates. 2 papers assess a specialist asthma nurse
and a secondary heart prevention clinic in primary care, these papers show that
standing order care can result in equivalent outcomes for patients compared to usual
care.
Conclusion:
Standing orders can be safe and efficacious in primary care settings, there is an
uncertainty about cost effectiveness.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Background:
A standing order is defined as a written protocol agreed between a medical
practitioner or dentist and another health professional which includes the provision of
a medication under defined circumstances.[1]
The 2002 Medicines (Standing Order) Regulations were passed to allow health
professionals who are not registered to prescribe, to administer medications under
specific written circumstances with the supervision of a registered provider.
This arose as a result of lobbying from rural health practitioners, who needed
legislation to support the use of standing orders which were being used increasingly
between rural nurses and doctors in response to the shortage of rural medical
practitioners (author personal communication, April 2008 Jean Ross).
Primary Health Care is defined in the New Zealand context in the Primary Health
Care Strategy:
“Quality primary health care means health care based on practical, scientifically
sound, culturally appropriate and socially acceptable methods that is:
 Universally accessible to people in their communities
 Involves community participation
 Integral to and a central function of the NZ health system
 The first level of contact with our health system”[3]
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Accessibility of services to patients in New Zealand as in many other countries is
being compromised by workforce issues. In June 2007 the New Zealand Medical
Association undertook an informal survey of practices in New Zealand that had self
identified as having stopped taking on any more patients. 50 practices responded to
the survey, reasons for ‘closure’ included:

“Too busy and unable to service existing patients’
 “Long waiting times to get an appointment”
 “More appointments since capitation and lower patient fees”
 “Need to maintain standards” [4]
There is a growing disparity between the number of active GPs and patients to
service, resulting in ever greater pressures on the health workforce. Figures 1,2.
Figure 1 The New Zealand Population 1997 – 2007
Population Growth 1997-2007
4,300,000
4,200,000
4,100,000
4,000,000
3,900,000
3,800,000
3,700,000
3,600,000
3,500,000
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Figure 2 The active GP workforce 1997 – 2003
Number of active GPs
3250
3200
3150
3100
3050
3000
2950
2900
2850
2800
2750
1997
1998
1999
2000
2001
2002
2003
There is however a growing number of active nurses in New Zealand, many of whom
are working in primary care. Figure 3.
Figure 3. Active Nurses in New Zealand 1997 – 2004.
Number of Nurses 1997-2004
36000
35000
34000
33000
32000
31000
30000
29000
28000
27000
26000
1997
1998
1999
2000
2001
2002
2003
2004
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
(Source : NZ Health Information Service
http://www.nzhis.govt.nz/stats/genpracstats.html)
The Health Workforce Advisory Committee has detailed the increasing pressure on
General practice services which other GP organizations have been heralding for years.
In Australia a ratio of 111.4/100,000 was set by the Australian Medical Workforce
Assessment Committee as a recommended target, in New Zealand we achieve 72
/100,000 on average, although an ideal ratio of GPs per head of population has not
been determined the Health and Disabilities Act of 1993 set a ratio of 1:1400 as the
minimum for issuing a notice to practice, and nationally this has been achieved[5] .
However many of these doctors are based in urban centres and if New Zealand was to
reach the Australian guideline level we would need an extra 1000 GPs, and rurally to
achieve a ratio of 1:1500 patients in rural areas an extra 107 GPs are required. [6]
In response to the growing crisis the New Zealand government has announced an
increase in training places for General Practitioners from the current 54 to 129 in 2009
and 154 in 2010, they have also promised an increasing number of undergraduate
training places, and are piloting the development of rural pathways and bonding
schemes that will encourage people to consider the rural medical life[7].
New Zealand has a long tradition of relying on overseas trained doctors to fulfil
workforce needs, but the World Health Organization has asked for all countries to
improve the way that they utilize their current workforce rather than ‘poach’ doctors
from other countries, many of which have critical shortages of medical professionals
themselves (Figure 4)
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Figure 4. Countries with a critical shortage of health service providers.
A number of provider groups have been able to prescribe independently from medical
practitioners for some years including midwives, dentists, and nurses. In isolated rural
settings the Rural Nurse Specialist role has been developed and there is a growing
number of Nurse Practitioners, 34 in July 2007 and growing monthly (49 in December
2008 , author personal communication New Zealand Nursing Council.)
But the extensive education, supervision and legislative requirements needed to
ensure safe independent prescribing of the wide range of medications available in
General Practice are limiting factors on the number of nurse practitioners who are
going to be able to adopt this scope of practice.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Although Laurant et al in a systematic review of studies where nurses substitute for
doctors in caring for patients[8] show that “appropriately trained nurses can produce
as high quality care as primary care doctors and achieve as good health outcomes for
patients “, nurses do not necessarily value this role,[9, 10] and where nurses are able
to prescribe to a formulary they may not do so because the formulary medicines are
limited in scope or not valued as part of the service [11] or they may lack confidence
and rather prescribe using standing orders which have the institutional support of
medical colleagues[12].
In New Zealand we know that about a quarter of patients who attend General
Practices also see a practice nurse, as identified by Lightfoot et al in their survey of a
sample of patient encounters in the Waikato taken from 4 weeks over the year 1991 –
1992. [13]
When patients see the practice nurse alone they tend to be seeing them for follow up,
asymptomatic issues, or single issues with limited diagnostic uncertainty, which may
be suitable for standing order care.
It appears that GPs are prepared to delegate responsibility within the practice team;
Jenkins-Clarke et al collected data from 10 UK practices over a 2 week period
including workload and delegation diaries from practices nurses, district nurses,
health visitors, and GPs. They also had researchers observing 836 consultations,
during which activity was recorded every 30 seconds, the GP and researcher then
agreed what activity could be delegated and to whom, and ran focus group discussion
exploring the issues around delegation.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
They determined that of 141 GP consultations, 17% of the total could have been
delegated entirely, and that around 40% of the content of the individual consultations
could be delegated to others. Figure 5.
Figure 5. Jenkins-Clarke – potential for delegation in consultations.
Patients needing advice and reassurance, screening activities, treatment of skin
complaints and ‘prescribing’ were seen to be most easily transferable to other team
members. The teams recognised that individual consultations were often a complex
mix of activities that could not easily be split up between team members, and that
triaging patients who present into the appropriate level of provider would be required.
The willingness of patients to see other members of staff was addressed in this study
and was not found to be an issue. Two thousand patients were asked a variety of
questions relating to the accessibility of members of the team and, although about
two-thirds said they preferred continuity, nonetheless about 45% would have
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
preferred to see another doctor or a nurse if they could have seen one sooner than their
own GP. [14]
Using standing order care does have potential difficulties.
Watkins and colleagues found in a study of hypertensive patients who had access to
either nurses or GPs working to an agreed protocol that more experienced nurses
tended to retain patients under their own care rather than adhering to the agreed
regimen, in particular when the problem was solely poor control of hypertension; it
appeared that this happened more often when patients were not compliant either with
dietary advice or medication regimens.
Nurses retained 36% of patients that should have been referred, but it has to be said
that doctors retained 40% of patients that could have been transferred to the nurses’
clinic. [15]
Over the 16 months studied there was no statistical difference in the outcomes in any
group of patients, those who saw the nurse alone, had shared care or saw the doctor
alone. All had an equal chance of an improvement in blood pressure control, and no
increased risk of adverse effects of medication or complications of disease.
One of the hopes for shared care and extending nursing roles in primary care is that it
will free up doctors to care for more complicated patients but in a randomized before
and after trial Laurant et al looked at the effect on General Practitioner workload of
introducing nurse practitioners working with patients with chronic obstructive
pulmonary disease, asthma, dementia, or cancer. The main outcomes were the
objective workload, derived from 28 day diaries, the number of contacts per day for
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
each of three conditions (chronic obstructive pulmonary disease or asthma, dementia,
cancer), type of consultation (in practice, telephone, home visit), and time of day
(surgery hours, out of hours). Subjective workload was measured by using a validated
5 point questionnaire.
Outcomes were measured six months before and 18 months after the intervention. The
study was not included in the formal review as nurses were not prescribing.
In this study there was no significant effect on perceived measures of workload, in
terms of available time, job satisfaction, inappropriate demands of patients or
perceived cost benefits, but there was an increase in patient contacts, particularly in
the group of patients with respiratory disease, perhaps because of case identification
and management issues raised by intervention, and a small insignificant drop in the
number of out of hours calls in the intervention group. The study did not show any
appreciable change in General Practitioner workload resulting from nurse practitioner
work. [16]
There is however an opportunity for an increased use of standing orders in the New
Zealand environment to enhance the role of practice nurses within General Practice
teams, and to extend access to prescribed medicines to patients.
Aims
The aim of this study was to determine what research is available to assess whether
nurses working with standing orders in primary care are able to provide safe and
effective treatment, and to determine if there is any evidence that supports an
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
argument that nurses using standing orders will provide more cost effective treatment
than doctors.
Methodology
The author set out to identify English language published papers of randomized
controlled trials that compare usual care with standing order based care in primary
care settings.
Papers included in the study were primary data studies that describe randomized
controlled trials in a primary care setting. Included in the review are studies based in
general practices, family medical practices, rest homes and first point of contact
assessment clinics including walk in medical centres and out of hours general practice
clinics.
Studies included compare usual care from a medical practitioner with care provided
by another health professional utilizing written instructions that have been developed
by the primary care team including a prescription of medication.
Outcome measures considered include cost analysis, clinical outcomes and patient
satisfaction.
Papers were excluded if they were not randomized controlled trials, if they refer
solely to provision of immunization services, or application of dressings or
appliances, or if they were based in secondary care services.
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A search was performed in March 2007 using the Auckland Medical Library on line
services, including Medline, EMBASE, CINHL, EBM reviews
(CDSR,CDRCT,DARE, and ACP Journal Club), with search terms specific to each
database.
Search terms and results:
Combined searches for: “Randomized controlled trials” “Random allocation”
Combined searches for “Primary care” “Family practice” “General practice”
Combined searches for “Nurse” “Nurses” “Nurse prescribing” “Nursing”
The search strategy was refined with advice from the Auckland Medical School
library staff.
The intersection of the above terms revealed a total of 299 papers, 106 papers on
Medline, 92 papers on CINHL, 92 papers on EMBASE, and 9 papers on the
combined EBM search engines.
Further papers were sought from review of references of relevant papers and through
discussion with advisors from the Royal New Zealand College of General Practice
and other researchers working in nursing and standing order development in New
Zealand and at the New Zealand Ministry of Health. This identified a further 6 papers.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Of the 305 papers 235 were excluded as irrelevant to the study or duplicates on
review of the titles and abstracts of papers.
This left 70 papers for more detailed analysis and consideration for inclusion in the
review. (Appendix 1)
Papers were sourced through the University of Auckland library and reviewed by the
author using a predetermined review chart to identify studies for inclusion in the
study.
4 papers were unobtainable [17-20] their abstracts were reviewed and none of them
were felt relevant for inclusion.
The review chart enabled the papers to be summarized and an assessment made of the
study method, participants, and intervention and outcome measures.
Structure of Findings
Review of the papers identified 7 studies that detailed randomized controlled
interventions comparing outcomes when nurses working to protocols including
prescribing medications are compared to doctors in primary care settings.
3 papers by Greenfield et al examine the use of specific protocols of care in the
treatment of low back pain[21], headaches[22], and dysuria, frequency and vaginal
discharge[23].
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2 papers look at care comparisons and cost effectiveness of nurses used when patients
requesting ‘same day’ consultations are seen by nurses or doctors [24, 25].
1 paper examines nurse protocol led care as one intervention in promoting secondary
prevention of coronary heart disease [26] and 1 paper examined asthma management
outcomes comparing a nurse specialist clinic with usual care. [27]
These papers were critically appraised according to guidelines illustrated by Sackett
and others [28] in “Evidence Based Medicine – How to practice and teach EBM.”
The validity of the studies was considered by asking firstly whether the assignment of
patients was randomized, and if so whether the randomization was concealed.
Then an assessment was made of whether all the patients entered into the study were
accounted for and whether they were analyzed in the groups to which they were
randomized.
Because of the nature of the studies the clinicians involved could not be blinded to the
intervention, but an assessment was made of how the researchers were blinded to the
interventions at analysis.
Also an assessment was made of how the papers assessed the similarities of the
randomized groups at the start of the trial and how similarly they were treated.
The conclusions the authors drew from each study were then considered and
summarized for inclusion in the discussion of findings of the literature review.
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Results
The first 3 papers examine the use of specific protocols of care in the treatment of low
back pain[29], headaches[22], and dysuria, frequency and vaginal discharge[23] using
ordinary practice nurses working in primary care with protocols developed by the
researchers along with the nurses and GPs involved. Although these papers from the
1970’s have methodological flaws the patients and practitioners involved are typical
of primary care settings and these interventions are practical and easily applied in
General Practices today. These 3 papers compare outcomes in clinical care between
standing order intervention and standard care, but do not include any cost analysis and
only limited patient satisfaction measures.
Paper 1
Nurse-Protocol Management of Low
Back Pain[29]
How was randomization achieved?
Not clear how randomization was
achieved, walk in patients who self
identified to a triage clerk as having back
pain were ‘randomly allocated’ to nurse
or doctor treatment.
Was randomization concealed?
No
Were all patients entered into the study
No – 592 patients were allocated
accounted for?
randomly, 26% dropped out of the nurse
protocol group, 33% out of the doctor
group because either they were lost to
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
follow up or they had identified
themselves as having back pain when
they did not.
Were all patients analysed in the groups
Yes
to which they were randomized?
Were the researchers blinded to the
It is not clear whether the researcher who
intervention?
followed up the patients was blinded to
the treatment intervention or not.
How similar were the randomized
The groups were similar in age and sex
groups?
distribution, similar diagnoses were made
in each group suggesting similar clinical
characteristics at onset but no analysis is
made of past medical history, co
morbidities, ethnicity or education and
socioeconomic status of the groups.
How similar were the interventions?
The nurse protocol intervention included
referral to a physician if required, 46% of
patients were seen by both the nurse and
a physician.
Limited analysis is offered of those who
saw the nurse alone compared to those
who saw the doctor alone, and those who
saw both nurse and doctor.
The timing of follow up is unclear,
“within 5 weeks’ and there is a 5 day
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
difference in the timing of follow up
between the two groups, the significance
of this is that further time for recovery
has occurred for the physician only
group.
Significant events are assessed from notes
review which is estimated in the
American HMO system to miss 7.2% of
admissions.
Only admissions are considered
significant events.
Patient satisfaction and relief of
symptoms is assessed using a non
validated 9 point questionnaire with
response possibilities limited to positive
and negative.
No formal assessment was made of how
long patients spent with each health
provider, but it is estimated the nurses
spent twice as long with patients (20
minutes).
This paper is flawed in several ways that make the author’s conclusions less reliable.
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The lack of a clear randomization process that is concealed raises the possibility that
the triage clerk who randomly allocated patients was biased in that allocation. This
could have led to less severe patients being allocated to the nurse only arm of the trial.
The paper only details the results of patients who completed the trial, omitting a
significant number from each arm of the trail who were either not eligible to be in the
trial or lost to follow up, the only assessment of these patients is that they were similar
in number between the groups.
If the patients who were lost to follow up were consistently unhappy with their
outcomes because of complications this could significantly alter the final results.
The assessment of complications using a record review of admissions is very limited,
omitting potentially serious sequelae including neuropathy. The use of a non validated
2 way patient satisfaction questionnaire at 5 weeks to assess patient satisfaction is not
likely to yield useful information about outcomes[30].
The paper concludes that the majority of presentations were for simple low back pain,
that the application of nurse protocol management was safe and effective as there
were no significant differences between the groups studied, but the limitations of this
paper call into question the validity of these conclusions.
Paper 2
Protocol management of Dysuria, Urinary
Frequency, and Vaginal Discharge[23]
How was randomization achieved?
Not clear how randomization was
achieved, walk in patients who self
identified to a triage clerk as having
dysuria, urinary frequency, vaginal
discharge or irritation were assigned to
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either arm of the study
Was randomization concealed?
No
Were all patients entered into the study
Yes – 5 patients were either incorrectly
accounted for?
triaged or refused to be examined twice
Were all patients analyzed in the groups
Yes
to which they were randomized?
Were the researchers blinded to the
It is not clear whether the researcher who
intervention?
followed up the patients was blinded to
the treatment intervention or not.
How similar were the randomized
The study makes no reference to an
groups?
analysis is made of age sex, past medical
history, co morbidities, ethnicity or
education and socioeconomic status of
the groups entering either arm of the trial.
How similar were the interventions?
The study design allocated patients to
assessment by both the nurse and a
physician, with outcome treatment
determined by which provider saw the
patient last.
Comparisons were made between the
outcomes of the two groups and an
analysis of treatment that would have
been applied if there was a nurse only
intervention.
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There is a lack of clarity around randomization method in this trial. The methodology
tries to limit bias by exposing each patient to both physician and nurse protocol
treatment.
Follow up by telephone questionnaire is not clearly blinded and follow up occurs
‘within a week’ which may not allow enough time for complications and treatment
failure to occur.
Only a single nurse was involved in this study and the conclusions drawn are severely
limited by the dependence upon this single practitioner’s skill and assessment.
In order to assess both the process and the outcomes of using a protocol the authors
randomized patients into groups where they were initially assessed by a nurse who
made a protocol decision which was then assessed by a doctor. The other group of
patients was assessed initially by doctor, and then handed on to the nurse who applied
the protocol care.
The authors compare how the nurse using the protocol and physicians record the
history and physical examination of patients.
Of 146 patients the history taken is ‘essentially’ identical in 139, and where 6
physicians have missed significant elements of the history, only one nurse has done
so. They compared the nurse and doctor physical examinations, and assumed that all
the examinations by a doctor where correct. This assumption was not verified by
assessment of patients by an independent practitioner. In 9 cases they report a
significant difference between the nurse and doctor physical findings, but this did not
result in different management decisions being made.
In this study the nurse and physicians performed an assessment of the presence of
bacteruria and pyuria using a microscope at the time of examination, and the authors
compared these findings to a ‘gold standard’ assessment by a laboratory.
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Both doctors and the nurse agreed on their findings and were incorrect in only 4 out of
58 cases of assessment of urine sediments, and 1 assessment of the presence of thrush
in vaginal discharge.
The study did not report on the assessment of sexually transmitted diseases other than
trichomonas in the patient group.
There was almost complete agreement between nurses and doctors on appropriate
therapy, all patients who should have been referred to the physician were referred and
no patients who were referred were considered to have been referred inappropriately.
Patients in both treatment groups were improved or asymptomatic at follow up, only 3
out of 146 patients did not report any improvement in symptoms, one who had an
allergic reaction to medications, and 2 who had an initial diagnosis of ‘non specific
vaginitis’ but later were treated for thrush.
Although the authors do not assess the length of time taken in consultations they
conclude that since 90% of patients could have been treated by the nurse without
referral to the doctor, this would have saved the doctor’s time.
Although the study depends on a single nurse it shows an equivalent outcome in the
treatment of UTI, dysuria, and vaginal discharge comparing nurse protocol care
including prescription with physician care.
Paper 3
A headache protocol for nurses[22]
How was randomization achieved?
Not clear how randomization was
achieved, walk in patients who self
identified to a triage clerk as having
headache were ‘randomly allocated’ to
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nurse or doctor treatment.
Was randomization concealed?
No
Were all patients entered into the study
No – 545 patients were allocated
accounted for?
randomly, 14% dropped out of the nurse
protocol group, 13% out of the doctor
group. “Over 90%” of those who dropped
out were “lost to follow up”; there is no
analysis of this group offered.
Were all patients analyzed in the groups
Yes
to which they were randomized?
Were the researchers blinded to the
It is not clear whether the researcher who
intervention?
followed up the patients was blinded to
the treatment intervention or not.
How similar were the randomized
The groups were similar in age and sex
groups?
distribution, similar diagnoses were made
in each group suggesting similar clinical
characteristics at onset but no analysis is
made of past medical history, co
morbidities, ethnicity or education and
socioeconomic status of the groups.
How similar were the interventions?
The nurse protocol intervention included
review of all patient notes by a physician
and referral to a physician if required,
45% of patients were seen by both the
nurse and a physician.
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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Limited analysis is offered of those who
saw the nurse alone compared to those
who saw the doctor alone, and those who
saw both nurse and doctor.
The timing of follow up is unclear,
“within 5 weeks’ and there is a 6 day
difference in the timing of follow up
between the two groups, the significance
of this is that further time for recovery
has occurred for the physician only
group.
Significant events are assessed from notes
review which is estimated in the
American HMO system to miss 7.2% of
admissions.
Only admissions are considered
significant events.
Patient satisfaction is assessed using a
non validated 9 point questionnaire with a
5 point response.
No formal assessment was made of how
long patients spent with each health
provider, but it is estimated the nurses
spent twice as long with patients (20
minutes).
28
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
This paper is flawed in several ways that make the author’s conclusions less reliable.
There is a lack of clarity around the randomization process the triage clerk who
“randomly allocated” patients could have been biased in that allocation and referred
less severe patients to the nurse only arm of the trial.
The paper only details the results of patients who completed the trial, omitting a
significant number form each arm of the trail who were either not eligible to be in the
trial or lost to follow up, the only assessment of these patients is that they were similar
in number between the groups.
If the patients who were lost to follow up were consistently unhappy with their
outcomes because of complications this could significantly alter the final results.
The paper’s authors report that the diagnoses made by the nurses using the protocols
were similar to those of physicians, but that physicians named a wider number of
diagnoses. The authors acknowledge that the diagnoses made are ‘presumptive’ and
not compared to a definitive ‘gold standard’, the comparison between the diagnoses
may mean that the physicians and the nurses using the protocol are equally poor at
making a correct diagnosis of the cause of a headache.
The presumption is made that if patient satisfaction scores are high then a good
outcome has been achieved, patients may be expressing high levels of satisfaction
with the process without necessarily a resolution of symptoms.
The assessment of safety is limited to an analysis of whether or not the patients were
later admitted to hospital, assuming that, based on another review 7.6 % of patients
may be admitted outside of this patient group health care plan and therefore not be
assessed. This assessment has significant potential to miss serious sequelae. 20% of
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patients in each group admitted they had sought help for their symptoms elsewhere
since the encounter; no analysis is made of this subgroup.
The authors try to further assess the safety of their protocol by applying the same
decision making process to a retrospective review of notes of patients admitted with
significant intracranial pathology. They conclude that the protocol would have
resulted in the nurse referring the patient to a physician in all cases except one – a
patient with a brain tumour whose initial presentation was atypical.
The patient satisfaction assessment process shows a significantly greater level of
satisfaction in the nurse protocol group compared to the physician only group, no
analysis is made of the group that only saw the nurse as opposed to those who were
referred by the nurse to the physician, and no assessment is made of the time taken
with patients, although it is estimated that nurses spent twice as long with patients
than did physicians (20 mins Vs. 10 mins)
Although this study has serious flaws, it does indicate that nurses supported by
physicians and working to a protocol that includes the provision of medication can
provide adequate care for patients presenting with headache.
The next two papers look at care comparisons and cost effectiveness of nurses used
when patients requesting ‘same day’ consultations are seen by nurses or doctors [25,
31]. These papers are set in UK primary care and involve patients typical of general
practice settings, the nurses involved were well supported within the primary health
care teams and results are generalisable to other primary care settings. These studies
are well designed and review patient safety satisfaction, clinical outcomes and cost
and are similar in reviewing patients requesting same day consultations.
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Paper 4
Randomized controlled trial of nurse
practitioner versus general practitioner
care for patients requesting ‘same day’
consultations in primary care.[31]
How was randomization achieved?
Patients requesting same day
consultations who were prepared to see
either a doctor or a nurse were consented
on arrival and randomized.
Practices chose either a ‘by day’ or
‘within day ‘randomization.
“by day’ randomization was block
allocated to ensure a balance of days
between nurse and doctor availability.
Was randomization concealed?
Yes – external generation
Were all patients entered into the study
Yes
accounted for?
Were all patients analyzed in the groups
Yes
to which they were randomized?
Were the researchers blinded to the
It is not clear whether the researcher who
intervention?
analyzed the data from patients was
blinded to the treatment intervention or
not.
How similar were the randomized
The groups were similar in age, sex, and
groups?
social class distribution. There were no
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significant differences in diagnosis,
morbidity, discomfort or concern at entry
into the trial.
How similar were the interventions?
Patients either saw a nurse practitioner or
a general practitioner, the ability of each
was equal in terms of process of care and
provision of treatment, investigation,
advice and follow up.
This well designed randomized study demonstrates that nurse practitioners working
alongside GPs in primary care setting can provide an equivalent quality of service
with similar outcomes to patients presenting requesting same day consultations.
The authors determined a sample size calculated to give 90 % power at a significance
level of 5% , they did not achieve their pre set target of 2000 patients recruited in the
trial, but the 1368 included in the analysis were sufficient for them to able to present
results with 95% confidence intervals throughout.
90% of patients entering the trial were reporting some or a great deal of discomfort.
The majority had upper respiratory tract infections, patients who seemed too ill, were
unable to understand the consent, and those requesting emergency contraception had
been excluded from the trial the latter because of the need for follow up
questionnaires and potential patient embarrassment.
At two weeks most patients in both groups reported an improvement in symptoms and
decrease in concern, with no difference in outcome for either group.
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Patient satisfaction, measured using validated scales, showed a significant improved
satisfaction amongst patients receiving nurse practitioner care compared to GP care,
particularly amongst children.
Nurse consultations were significantly longer, and patients reported getting more
information about the cause of the illness, how to ease symptoms and what to do if the
symptoms did not resolve from the nurse.
There was no significant difference in the prescriptions provided, or investigations
ordered and although the nurse practitioner group advised people to return more often,
there was no significant difference between the re-attendance of patients between the
groups.
Only 32 % of patients who saw a nurse said they would see a nurse again in the same
situation, where 8% of those who saw a GP said they would see a nurse in the same
situation.
This latter finding may reflect a lack of patient confidence and understanding of the
role and skills of a nurse practitioner.
Paper 5
Randomized controlled trial comparing
cost effectiveness of general practitioners
and nurse practitioners in primary
care.[25]
How was randomization achieved?
Patients presenting for same day
consultations were consented and coded
block randomization generated from
random number tables were allocated at
the start of each session by a researcher.
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Was randomization concealed?
Yes
Were all patients entered into the study
Yes. The study excluded those who were
accounted for?
too ill, children under 16 years of age,
temporary residents and patients with
language and reading difficulties.
Were all patients analyzed in the groups
Yes
to which they were randomized?
Were the researchers blinded to the
It is not clear whether the researcher
intervention?
analyzing the data was blinded to the
intervention or not.
How similar were the randomized
The patients randomized were similar in
groups?
age, sex and presenting complaint.
How similar were the interventions?
Patients either saw a nurse practitioner or
a GP, who were equally able to assess,
prescribe, investigate and arrange follow
up.
This well designed randomized study again shows that nurses are able to deal
adequately with patients presenting for same day consultations with similar outcomes
to GPs.
The authors found that nurse practitioners spent significantly longer with patients than
did GPs, (mean 11.57 minutes compared to 7.28 mins) and ordered significantly more
investigations (Odds ratio 1.66). Nurses were significantly more likely to ask patients
to return for a reassessment (Odds ratio 1.93), and patients were more likely to make a
return visit to see a GP if they had seen a nurse.
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In 12.6% of consultations discussed the patient with the GP, and arranged for the
patient to be seen by the GP in 4.1% of consultations.
Patients were significantly more satisfied with the consultations with the nurse
practitioners, even after the length of consultation had been accounted for.
There was no difference in health status outcome between the two groups.
The authors assessed the health service costs incurred by patients who saw the nurse
compared with the GP, including basic salary costs, and costs of prescriptions, tests,
referrals, and return consultations.
There was no significant difference between the two groups, although nurse costs
were slightly lower with the mean nurse consultation costing 18.11 pounds and GP
consultation 20.70 pounds.
The authors comment that if additional costs including lifetime training were taken
into account GP cost would be significantly higher and that if nurses reduced their
consultation time and return consultation rate the nurse cost would also significantly
drop.
The final 2 papers examine nurse protocol led care as one intervention in promoting
secondary prevention of coronary heart disease [26] and asthma management
outcomes comparing a nurse specialist clinic with usual care .[27] The first paper is
firmly set in primary care and uses practice nurses employed within primary care
settings, the second uses specialist asthma nurses but is included here as they
prescribe medication in collaboration with primary care teams.
Both papers compare clinical outcomes between intervention and control groups
including recorded evidence of standards of care and utilization of services.
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Paper 6
Cluster randomized controlled trial to
compare three methods of promoting
secondary prevention of coronary heart
disease in primary care[26]
How was randomization achieved?
All patients with coronary heart disease
in the 21 recruited practices were
identified by external assessment of the
GP records. 2142 patients identified.
Practices current assessment of CVS risk
was audited and practices allocated to one
of 3 different strata according to this
assessment.
Practices were then randomized to ‘audit
and feedback’ ‘recall to GP’ and ‘recall to
nurse clinic’ groups using a block
random allocation, based on computer
generated random numbers.
Was randomization concealed?
Yes – a statistician blinded to practice
identity allocated the practices to
intervention.
Were all patients entered into the study
Yes
accounted for?
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Were all patients analyzed in the groups
236 of the recruited 2142 patients died,
to which they were randomized?
moved practice or were found to have
been originally misdiagnosed before the
second audit, a further 82 were had died,
moved away or were too ill to attend
assessment after the second audit.
Of the remaining patients 75% responded
to the final questionnaire and 74 %
attended the final assessment.
Were the researchers blinded to the
Yes – the follow up clinical assessment
intervention?
was done by a nurse blinded to the
intervention.
How similar were the randomized
The patients were similar in age, sex,
groups?
original diagnosis, morbidity and
smoking status.
How similar were the interventions?
All practices had the same audit
information as the baseline group, the GP
recall group agreed guidelines with a
medical researcher, and the nurse clinic
recall group developed practice based
guidelines and received educational
intervention regarding implementation.
The authors defined an adequate assessment at baseline as one in which since
diagnosis a record had been made of:
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1. Blood pressure, and if this was elevated a record of follow up readings in the
past 2 years.
2. Cholesterol, and if elevated a record of follow up readings in the past 2 years.
3. Smoking habit, and if smokers a record of review in the past 2 years.
After intervention at 18 months the same criteria applied except that blood pressure
readings in the last two years were mandatory.
They also recorded treatment with hypotensive drugs, lipid lowering drugs and
antiplatelet drugs.
At baseline 30% of patients were adequately assessed, the increase in adequate
assessments at 18 months over the audit group was 33% in the nurse recall group and
23% in the doctor recall group.
Intervention showed a significant improvement over audit alone, but no significant
difference in adequate recording of assessments comparing doctor and nurse recall
groups.
In drug treatments at baseline 68% were already being treated with hypotensive
agents, and there was no significant change after intervention. There was no
significant difference in the increase in the prescribing of lipid lowering drugs in the
intervention groups compared with audit groups.
The nurse recall group did prescribe significantly more antiplatelet medications, than
the audit group and the GP recall group (by 8 and 10 % respectively), but the authors
did not assess self medication rates which may have had a significant impact on
prescribing.
There were no significant or clinically important differences between all three groups
in mean blood pressure, cholesterol, smoking status, or quality of life scores.
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The lack of significant differences between these groups may show that performing an
audit alone increases the quality of assessment and treatment of coronary heart
disease, these benefits can be equally attained through nurse or doctor interventions.
The authors also reflect that results may have been confounded by an external health
authority run patient initiative, that practices were allocated to intervention without
prior assessment of educational needs and thus practices with high level functioning
nurses may have been allocated to the audit group and vice versa, that there may have
been little room for improvement in smoking cessation, or blood pressure control.
Lipid lowering medication prescribing was poor both before and after intervention,
perhaps reflecting a reluctance to prescribe amongst practices with prescribing
budgets, a wish to avoid polypharmacy and that not all doctors were involved in
setting the guidelines within practices, these doctors may have not been committed to
implementing the guidelines.
The authors conclude that setting up a coronary disease register increases the follow
up and adequate assessment of risk, but that this does not necessarily affect outcomes.
That follow up by nurses is as effective, and may be more effective than doctors, but
that even adequately followed up patients do not necessarily get the recommended
preventative drugs.
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Paper 7
Specialist nurse intervention to reduce
unscheduled asthma care in a deprived
multiethnic area: the east London
randomized controlled trial for high risk
asthma (ELECTRA)[27]
How was randomization achieved?
Practices were allocated to intervention
group or control practice using
stratification by size, hospital admission
rate, training practice status, practice
nurse employment and asthma training of
practice nurse.
Asthmatic patients were identified after
attending the accident and emergency
department of the Royal London Hospital
or the out of hours GP service.
Was randomization concealed?
This is not clear
Were all patients entered into the study
Yes
accounted for?
Were all patients analyzed in the groups
Yes
to which they were randomized?
Were the researchers blinded to the
Yes – at medical record review, follow up
intervention?
interview and at analysis.
How similar were the randomized
Control and intervention practices were
groups?
similar in partnership size, employment
of practice nurse, level of asthma training
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of nurse, training practice status, and
hospital admission status for asthma.
Patients were similar in age, sex,
ethnicity, language, housing and
employment, smoking and diagnosis and
current treatment.
How similar were the interventions?
The control group practices had an
educational visit from nurses and patients
had inhaler technique assessed in a nurse
led clinic. Intervention practices had 2
educational visits. The intervention
included a system to identify asthmatic
patients and flagging their notes.
Patients from intervention practices were
seen by a specialist asthma nurse who
discussed a self management plan, and
provided rescue corticosteroid and a peak
flow meter and chart. Where language
was a problem a written and bilingual
information service was provided.
Patients who were unable to understand a
self management plan were educated and
encouraged to contact their GP should
things worsen. Nurses reinforced advice
with a further face to face or telephone
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conversation.
The authors looked at how the intervention affected the unscheduled asthma care
behaviour of patients, and also quality of life measured by generic and respiratory
specific scales.
Data was obtained by review of primary care notes, hospital admission and accident
and emergency care notes, by face to face or telephone interview at 2,6,9 and 12
months after recruitment.
Intervention with the nurse delayed first attendance and percentage of patients
attending for unscheduled asthma care in the year after the appointment. Overall the
rates of attendance in the intervention group were 1.98 and in the control group 2.36.
There was no difference in use of emergency corticosteroid, or self management
behaviour or quality of life scores between groups.
Discussion:
Patient Satisfaction with Standing Order Care :
The assessment of patient satisfaction by Greenfield et al is limited but shows a
positive bias towards nurse protocol management, Moher and Griffiths do not
formally assess patient satisfaction, but show no difference in standardized “quality of
life” scores in patients accessing nurse led care in chronic disease management.
Kinnersley and Venning both show in validated patient satisfaction questionnaires a
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higher level of satisfaction with nurse led care compared to normal care, even after
the increased length of consultations is taken into account.
It appears from these studies that nurse led standing order care is appreciated by
patients, but questions have been raised about how important patient satisfaction is in
measuring quality of care, since patient satisfaction does not necessarily reflect high
quality care[32, 33].
Patient Benefit / Harm.
None of the studies analysed showed any difference in outcome measures comparing
nurse led standing order care compared to usual care, apart from the study by Griffiths
et al which showed fewer emergency care visits and a delay in the first episode of
emergency care in patients receiving specialist asthma nurse intervention.
Nurses are shown in theses studies to use protocols effectively and refer patients
appropriately, and there is no difference in prescribing volumes comparing nurses
using standing orders and usual care.
Cost Effectiveness.
When nurses apply protocol care Greenfield et al conclude that this saves doctor time,
although they make no formal assessment of this, they estimate that nurses spend
around 20 minutes longer than doctors with each patient.
Venning and Kinnersley both show that nurses ask more patients to return for follow
up, but actual re-attendance rates within 2 weeks varies.
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Nurses in Venning’s study order more investigations than doctors, and spend longer
with patients, this results in an increasing effect on costs.
This aspect of care was specifically analysed by Venning and overall health care costs
were shown to be slightly lower in the nurse led care – but this was not statistically
significant.
Comparison with other studies
This literature review has identified significant limitations in the available data
regarding the assessment of the effectiveness and safety of standing order use in
primary care settings.
Where randomized studies are available they do confirm the findings of the
systematic review by Laurant et al [8] that nurses can provide care which is equally
effective, safe and acceptable to patients as doctor care, with potentially greater levels
of patient satisfaction. Standing order care has variable effects on overall health care
costs and may not result in lower costs overall to the health care system unless nurses
take less time with patients, recall fewer patients, and order fewer tests.
The distinction between nursing practice and medical practice is a complex topic
beyond the scope of this discussion but evidently nurse intervention is not designed in
these studies to substitute for medical care but to supplement it, the cost effectiveness
of standing order care is compromised by the length of time nurses spend with their
patients, which also results in greater patient satisfaction scores. In primary care the
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benefits from extending services to patients through standing orders by nurses are
sufficient to justify the cost.
Strengths and weaknesses of the study
The author worked alone in this assessment, the lack of an independent review of
eligible papers means the study is open to observer bias, but this is limited by the
small number of papers identified, and the consistent use of a template to compare all
papers in the same way.
The use of several on line databases, review of references, and discussion with other
researchers undertaken is likely to have captured most papers but there is a lack of
consistency in the literature around terminology relating to care under standing orders,
which are called ‘patient group directives’ in the UK for example, and this may have
meant that papers reporting care under standing orders may have been omitted form
the review.
Relevance to NZ
The use of standing orders in primary care settings is supported by the limited
literature, which suggests that they can be used safely, that patients are happy with the
levels of care they receive but that they may not result in significant cost savings to
health service compared to usual care.
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As increasing pressure on workforce availability progresses internationally, standing
orders provide a safe and effective method of extending the role of practice nurses and
increasing access to services to patients.
Key points
The papers identified involving Sheldon Greenfield [22, 23, 29] are limited in patient
numbers and by the lack of clarity around method of randomization, but illustrate that
nurses providing care alongside doctors using protocols can safely prescribe
medications for a variety of conditions safely and effectively.
Patients requesting same day care are studied by Kinnersley[31] and Venning[25] and
again similar outcomes to usual GP only care is achieved, with evidence that patients
are more satisfied with the care provided, perhaps because nurses spend more time
with patients and are considered to provide more information, and that this does not
come with an increased cost to the health service .
Moher[26] and Griffiths[27] show that nurses providing intervention for chronic
diseases including prescription provide equivalent care in longer term outcomes and
management to usual GP only care.
Care provided under standing orders is acceptable to patients.
Care provided under standing orders is effective and safe for patients.
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Care provided under standing orders does not cost the community more, and may cost
less than standard care.
Recommendations for further research generated by literature review
Further research is needed into the current utilisation of standing orders in New
Zealand as the uptake of standing orders appears to be confined to rural isolated
practices.
Exploration of the perceived barriers and benefits of using standing orders within
primary health care teams will be valuable in learning how best to promote standing
order use.
Conclusions
Standing orders provide a safe, acceptable and cost effective way of extending the
role of primary health care nurses and improving access to patients for care.
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Part 2 Research Project
ABSTRACT
2 studies related to the literature review findings were undertaken.
The first describes the use of standing orders in a single rural practice in New
Zealand.
The second a purposive survey of practice nurses and doctors to begin to understand
the perceived barriers to and advantages of the use of standing orders in primary care.
The studies illustrate that standing order use can be acceptable to patients and staff
over a wide range of conditions, and that perceived barriers of responsibility, safety,
and time are balanced with the benefits that flow from extended nursing roles, and a
perception of better patient access to care.
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Paper 1
(Jan 2008 Pending publication in Kai Tiaki Nursing New Zealand )
Use of standing orders in a rural New Zealand general practice.
Abstract
Aims and Objectives:
To report on the use of standing orders in a New Zealand Rural General Practice.
Background:
There is no published literature about the use of Standing Orders in General Practice
in New Zealand, internationally standing order use in primary care is poorly reported.
Design:
A prospective study of the use of standing orders over a six month period in a single
rural practice.
Methods :
Standing order use was recorded over a six month period using the Medtech practice
management system and analysed using standard Microsoft Excel tools.
Results:
113/2138 (5%) of nurse consultations resulted in a prescription issued under standing
orders. 71/113 (63%) were for an antibiotic principally to treat impetigo or urinary
tract infection. Standing orders are used daily for a variety of commonly presented
conditions. More females than males are treated under standing orders and more
Māori patients.
Conclusions:
This paper demonstrates standing orders as an option in increasing access of patients
to medical treatment through the use of primary care based nursing skills.
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Relevance to Clinical Practice:
Standing orders provide an option to extend the role of the practice nurse in primary
care, allowing wider access for patients to medical treatments.
Introduction.
In response to workforce shortages,[6] particularly in rural areas, the New Zealand
Ministry of Health developed legislation in 2002 that allowed nurses and other
approved health professionals to prescribe or supply medications under “Standing
Orders.” [1] In 2005 legislation was passed allowing the development of a small but
growing Nurse Practitioner workforce with independent prescribing rights within
limited scopes of practice.[34] .
The educational requirements involved in becoming a Nurse Practitioner mean it is a
role that will not appeal to many in the nursing workforce, expanding the nursing role
through standing orders is an alternative way of increasing access for patients to
prescribed medication.
A standing order is a written instruction issued by a medical practitioner or dentist, in
accordance with the regulations, authorising any specified class of persons engaged in
the delivery of health services to supply and administer any specified class or
description of prescription medicines or controlled drugs to any specified class of
persons, in circumstances specified in the instruction, without a prescription. [1]
There is no literature currently available reporting the use of standing orders in the
New Zealand context and the aim of this paper is to report on their use in a small rural
general practice.
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Context:
Opotiki is a small rural town on the coast of the North Island of New Zealand. It has a
population of 9,200 has a high proportion of Māori and has a relatively high degree
of social deprivation. The practice involved in this study has been a solo practice for
many years looking after an average of 2300 patients. The practice employs 2 practice
nurses and in 2002 decided to widen the practice nurses scope of practice by
developing a number of standing orders. This was mainly at the suggestion of the
nurses who felt they were seeing a number of patients with health complaints that they
were happy to manage independently of the GP.
During regular clinical meetings, the 2 nurses and the general practitioner discuss
cases seen and consider whether or not patients would benefit from developing a
standing order around a particular condition. After in house training, once the nurses
feel confident in their ability to diagnose the condition, the team uses available
guidelines for example from the New Zealand Guidelines Group [35] to review
appropriate management and treatment. Using the data available from the Ministry of
Health’s pharmaceutical ‘watchdog’ Medsafe [36] a standing order is then written,
including details of the condition and patients to whom it applies, dosage and
administration guidelines, contraindications to the medications, instructions to be
given to the patient and follow up required. To date the team has developed 17
standing orders, these are critically reviewed annually
Methods.
This is an analysis of those standing orders used in a six month period.
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Box 1. Medications authorized for use under standing orders
Amoxycillin, Erythromycin,
Flucloxacillin, Trimethoprim,
Chloramphenicol ointment and drops,
Clotrimazole, Metroniadazole,
Colchicine, Diclofenac,
Depo Provera,
Oral Contraceptive (levonorgestel 0.15mg, ethinyl estradiol 30mcg)
Box 2. Conditions with associated Standing Orders
Dental infection, Impetigo,
Urinary Tract Infection, Sore Throat,
Conjunctivitis, Ear Infection,
Vaginitis, Gout,
Contraception
We identified from the nurses’ records the number of encounters they had
recorded in a six month period and the number of these that had resulted in a
prescription. The age, gender and ethnicity of the patient in each instance, the
medication prescribed and the condition/standing order that was being applied was
recorded.
Results.
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The doctor sees an average of 30 patients a day where the nurse sees on average
12.5 patients a day in our practice. Of these consultations over the past 6 months
113/2138 (5%) have resulted in the use of one of the standing orders. The largest
group of clients receiving standing orders are those under 5 yrs.
Use of Standing Orders By Age
40
35
30
25
20
15
10
5
0
0-5yrs
6-14yrs
15-25yrs
26-40yrs
41-65yrs
65yrs +
Women (65%) were more likely to utilize standing orders compared to men
(35%). The practice has a 46% Māori population but sees more Māori than nonMāori patients, reflecting the higher health needs status. This is reflected in the
utilization of standing orders – 58% for Māori and 42% for non-Māori. The higher
usage of standing orders by Māori is reflected across the range of conditions for
which they are available.
The commonest standing orders used are those relating to infections - impetigo
45/113 (40%), urinary tract infections 14/113 (12%) and sore throat 12/113 (11%)
management. A prescription for contraception is issued less than once a week –
Depo Provera was prescribed on 8 occasions (7 prescriptions were for Māori
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women), oral contraceptives 5 times and the morning after pill once. There were
only two prescriptions related to the management of gout.
The most commonly prescribed medications were antibiotics - flucloxacillin (45
prescriptions), followed by amoxycillin (21), trimethoprim (14), erythromycin (3)
and chloramphenicol ointment (5). Clotrimazole was prescribed 5 times and
metronidazole once. There were only 2 prescriptions of diclofenac for gout and
none for colchicine.
Discussion.
There is limited literature on use of standing orders in primary care settings.
Generally the published literature suggests patients are happy with the levels of
care they receive and that standing order use is safe.[2, 8] Whilst the intent is to
free up the doctors time and to use the full extent of the skill of the practice team
there is no evidence from the literature that the use of standing orders saves
money.[25]
In the United Kingdom nurse prescribing has evolved since the Cumberlege
report in 1986 (Department of Health (1986) Neighbourhood Nursing: A Focus
for Care (Cumberledge Report). HMSO, London.) suggested that patient benefits
may flow from non medical prescribing, The Department of Health set up an
advisory group which in the Crown Report [37] recommended extending
prescribing rights to nurses, but it was not until 1992 that legislation was passed
which led to a limited prescribing formulary. Since this time non medical
prescribing has extended further from the development of Patient Group
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Directions, which are the closest parallel to standing order under New Zealand
legislation, into more widespread supplementary [38, 39]and independent
prescribing[40]. Although the literature shows that nurse prescribing is seen as
valuable by nurses [41] there is evidence to suggest that community based nurses
in the UK who have trained in the use of these tools do not use the skills they have
acquired, [12] through bureaucratic difficulties, lack of personal confidence, the
difficulty maintaining continuity of care with the patient record when prescribing
in the community, lack of support from local GPs, and a perceived lack of time in
clinics already busy with nursing tasks.
Independent nurse prescribing in New Zealand is in comparison at an early stage
of development [42] with currently a workforce of around 50 nurse practitioners
less than 10 of whom work in primary care of whom less than half have
prescribing rights (New Zealand Nursing Council personal communication
December 2008). There is no reported literature on the utilization of standing
orders in New Zealand although it is known that extensive use of standing orders
is made the remote rural practice of the South Island’s West Coast.
Although limited to a single practice this report provides preliminary data about
the use of Standing Orders in primary care in New Zealand.
It is interesting in that it highlights that standing orders have been used
preferentially in the management of women/females and Māori. This is partly a
reflection that women and Māori are more likely to visit the doctor and also may
reflect that women are more comfortable seeking treatment from a female (nurse)
than a male (doctor). Also the available standing orders are for conditions that the
nurses have identified as useful and around which they feel confident. There is a
skewing towards conditions that are female specific like contraception, vaginitis
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and urinary tract infections. The number of times that standing orders were used in
the 6 month period was less than expected - less than one prescription per working
day. However it does demonstrate that practice nurses are comfortable managing a
range of conditions with a limited list of standing orders. In particular they are
happy to manage common infections such as urinary tract infections, impetigo and
sore throats. Their role in providing contraception could also be extended –
although this report omitted patients seen in a school clinic context it was
interesting that there was only one prescription for the morning after pill provided
in the GP clinic setting. Teenage pregnancy is a problem in New Zealand and
wider advertising of the availability of the morning after pill could be considered.
The nurses value the ability to prescribe. One nurse commented that: “Standing
orders allow me to help patients immediately, rather than having the hassle of
getting them fitted in to the doctor, it is satisfying to be able to provide this level
of care.” This is tempered by an anxiety that they may be working outside their
scope of practice. This latter perception reinforces the need for protocols and
training to support the use of standing orders, particularly in general practice
where a wide range of undifferentiated conditions are encountered, working with
standing orders should not be confused with the independent prescribing of a
Nurse Practitioner.
Standing order legislation requires that the authorized prescriber physically “signs
off” the records detailing the use of a standing order. This is achieved using the
Practice Management System which allows the nurse to record the use of a
standing order next to a patient’s name in the appointment book. The doctor is
tasked with reviewing and annotating these records on a weekly basis.
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Medication is provided directly to the patient from the surgery’s drug cupboard, or
in the form of a prescription which has to be signed by the prescriber before being
taken or faxed to the local pharmacy.
All members of the team need to be confident that patients will be appropriately
cared for under a standing order regimen, where teams have regular clinical
meetings this confidence should grow as nurses understand their GP colleague’s
anxiety about diagnostic uncertainty and doctors appreciate the knowledge and
expertise of the nurses in their practice.
The safe use of standing orders within a practice team relies upon the confidence
that the nurse has in making a diagnosis and in correctly applying the medication
order as written. The legislation allows teams to develop these skills without
reference to extended educational requirements, university papers in diagnostic
technique and pharmacology may help to improve confidence but they are not
required for a nurse to be able to work with standing orders.
As increasing pressure on workforce availability progresses standing orders,
providing a safe and effective method of extending the role of practice nurses and
increasing access to services to patients.
Relevance to Clinical Practice
This report demonstrates the use of standing orders in a rural General Practice.
Extending nursing roles in clinical practice is one response to growing workforce
shortages and this study adds further information to this issue which is poorly
represented in the research literature. The author has developed a private access
website discussion forum to allow practices to share standing order templates and
provide a discussion forum. E mail [email protected] for further details.
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Limitations
This is a report of standing order use in a single rural practice and specific to this
setting, generalizations about standing order use cannot be made based on this
study.
This report was presented in part to the College of Practice Nurses Conference in
Tauranga in May 2008.
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Paper 2
Standing Orders in New Zealand Primary Care: Barriers and Benefits.
Abstract.
Aim.
To explore the perceived barriers to and benefits of the use of Standing Orders in
Primary Care Settings in New Zealand.
Method.
A purposive survey of practice nurses and doctors using and not using standing
orders.
Results.
Standing orders are seen to be useful adjuncts to standard care, extending the nursing
role and improving access to patients, but the implementation takes time and effort
and there is concern particularly from doctors about the medico-legal implications of
standing order care.
Introduction:
A standing order is defined as a written protocol agreed between a medical
practitioner or dentist and another health professional which includes the provision of
a medication under defined circumstances.[1]
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The 2002 Medicines (Standing Order) Regulations were passed to allow health
professionals who are not registered to prescribe, to administer medications under
specific written circumstances with the supervision of a registered provider.
This arose as a result of lobbying from rural health practitioners, who needed
legislation to support the use of standing orders which were being used increasingly
between rural nurses and doctors in response to the shortage of rural medical
practitioners (author personal communication April 2008 Jean Ross).
Standing order care has been shown to be effective, safe, and acceptable to patients,
but to have a variable effect on health services cost.[2]
Although some areas in New Zealand rely heavily on standing orders to provide care,
notably the West Coast of the South Island, the uptake and use of standing orders has
been poorly studied.
The aim of this survey was to explore how doctors and nurses perceive the benefits
and challenges of using standing orders in primary care, in an effort to understand
how standing orders can be best promoted for more extensive use.
Method.
A questionnaire was developed to be sent to a purposive sample of practices who had
expressed interest in taking part in further study of standing orders.
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The questionnaire and the rationale behind its development is explained in
appendix 2.
Practices involved in the study identified themselves during the 2007-2008 Royal
College of General Practitioners Conferences, the Rural General Practice Network
Conferences and the 2008 New Zealand Nursing Organisation Practice Nurse
Conference as being interested in issues around standing orders. This purposive
sampling method was used because given the low level of standing order utilisation in
New Zealand a random selection of practices would be unlikely to identify many
practices who are familiar with Standing Orders.
Approval for the study was obtained from the New Zealand Multi Regional Ethics
Committee.
The questionnaire used a Likert scale with a combination of stems linked to a 5 point
response from strongly disagree through neutral to agree, for reporting purposes
responses were consolidated into “agree, neutral, disagree.” Where responses were
ambiguous for example when two selections were made or absent a neutral score was
applied.
Large open text boxes were used to encourage additional comments around the issues
of perceived benefits and barriers to standing order care. Using this process it was
hoped that a combination of objective and subjective information could be gathered as
appropriate in an ethnographic study aimed at understanding perspectives around
standing order use.
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Analysis of the questionnaire was performed using standard Microsoft Excel tools and
the complete text responses were collated and after a period of reflection categorized
into themes.
Responses were sought from a practice nurse and a doctor from each practice, and the
practice was also asked to report on practice size and rurality and to detail their own
use of standing orders.
Results :
17 practices across New Zealand were sent questionnaires, a response was sought
from each practice, and from one doctor and one nurse from each practice, after two
weeks a reminder letter was sent to non responding practices, some practices returned
questionnaires from more than one doctor or nurse, all responses were included in the
analysis.
5 practices that did not use standing orders responded, 3 rural, 1 urban and 1 not
identified.
5 practices that use standing orders responded, 2 urban, 3 rural.
2 sets of questionnaires were returned uncompleted, one stating it was ‘sent in error’
the other stating the practice was too busy to complete a questionnaire. 5 practices did
not respond.
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There were 15 responses from GPs and 10 responses from nurses, the Rural Institute
of New Zealand database records that 19 nurses and 90 doctors work in the practices
contacted.
The 5 practices that responded that were using standing orders included an isolated
rural practice service a population of 1700 with a rural ranking score of 95, another
rural practice serving 840 patients with a rural ranking score of 75, a large rural
practice serving 13,200 with a rural ranking of 40 and a very large urban practice
with a population of 16,000, and another urban practice with a population of 4,600.
Based on reported tenths where one tenth is a morning or afternoon session, the small
rural practices had one full time doctor and nurse, the large rural practice 6 doctors
and 6 nurses. The smaller urban practice had 2 full time doctors, 1.5 full time nurses,
and the larger 13 full time doctors and 10 nurses. (Table 1)
There was a great variability across both groups, standing order users and non
standing order uses in the respondent practices, it is hard to define a ‘typical’ standing
order user practice in this small sample, but it may be that standing orders are used
across a wide variety of General Practice teams.
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Table 1 : Practice Characteristics
LIST SIZE
URBAN/
RURAL
RURAL
RANKING
NO. GPS
NO.
NURSES
SO
Practices
1
4140
U
-
2
1.5
2
16,000
U
-
13
10
3
840
R
75
1
3
4
1700
R
95
1
1
5
13200
R
40
6
6
1
4600
U
-
4
2
2
1200
R
35
1
1
3
3000
R
60
1
.5
4
5200
R
-
2
2.5
5
-
-
-
-
-
Non SO
practices
What Standing Orders are used?
Practices that are utilizing standing orders who responded to the survey were using
them for a wide variety of conditions and a wide variety of medications. (Table 2)
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Table 2 : Conditions and Associated Standing orders.
Condition
Medications
Tonsillitis
Phenoxymethylpenicillin, Erythromycin, Amoxycillin
Paracetamol,Pseudephedrine, Promthazine, Otrivine,
Otitis Media
Amoxycillin Cotrimoxazole
UTI
Ural,Trimethoprim, Norfloxacin, Amoxycillin
Impetigo
Flucloxacillin, Erythromycin
Bronchitis
Amoxycillin, Erythromycin, Cotrimoxasole
Chlamydia
Azithromycin
Gonorrhoea
Ciprofloxacin
Mycostatin,Clotrimazole, Diflucan,
Candida
Nystatin, Paracetamol.
Contraception
Postenor, Depo Provera, ECP, COC, PCP
Oxygen, Salbutamol, Adrenaline, Prednisone,
Asthma
Ipratroprium bromide
Conjunctivitis
Chloramphenicol
Analgesia
Paracetamol, Codalgin, NSAIDS
Constipation
Microlax, Phosphate enema, Oral laxatives
Otitis externa
Sofradx or Kenacomb
Acute sinusitis
Amoxycillin, Sudafed, Otrivne,Atrovent
Beestings
Antihistamines
D+V
Gastrolyte
Athletes foot
Clotrimazole/ Miconazole
Croup
Methylprednisone
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Chest Pains
Oxygen, GTN Spray, Morphine, Metoclopromide
Oxygen, Adrenaline, Promethazine, Prednisone,
Anaphylaxis
Salbutamol, Naloxan
Current legislation does not limit the range of medications or conditions that can be
treated under standing orders , this is determined by each practice and this is reflected
in the variability and scope of standing orders in use.
Who administers standing orders?
In this sample standing orders were administered only by nurses, described as
“practice” or “prime” or “advanced rural” nurses in these practices. No other
providers – pharmacists, midwife, or dentists were identified. This may reflect the
current nature of general practice teams.
Barriers to Standing Order Care :
The questionnaire data shows that doctors participating in this survey felt more
ambivalent about some of the challenges of utilizing standing orders than did the
nurses, in particular doctors saw more negatively about the medico-legal risk, the time
taken to develop standing orders, the need for supervision and the potential for
medical error and working beyond the bounds of competency.
There was a broad concurrence between nurses and doctors around statements that
standing orders are not a threat to the doctor patient relationship and that they are
acceptable to patients.
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Table 3 Responses to Statements about the challenges of standing orders.
Agree
Neutral
Disagree
Nurse
7 (70%)
2 (20%)
1 (10%)
Doctor
9 (60%)
4 (27%)
2 (13%)
Nurse
8 (80%)
2 (20%)
0 (0%)
Doctor
9 (60%)
5 (33%)
1 (7%)
Nurse
9 (90%)
1 (10%)
0 (0%)
Doctor
10
4 (27%)
1 (7%)
SOs Allow Non Prescribing Staff to Work Beyond
Their Level of Competence
SO led care is not acceptable to patients
SOs significantly decrease the profit that practices
can generate
(66%)
SOs increase the risk of medication error
Nurse
9 (90%)
1 (10%)
0 (0%)
Doctor
3 (20%)
7 (47%)
5 (33%)
SOs are a major threat to the doctor patient
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relationship
Nurse
9 (90%)
1 (10%)
0 (0%)
Doctor
10
4 (27%)
1 (7%)
(66%)
SOs need too much supervision
Nurse
8 (80%)
2 (20%)
0 (0%)
Doctor
5 (33%)
6 (40%)
4 (27%)
Nurse
6 (60%)
2 (20%)
2 (20%)
Doctor
3 (20%)
2 (13%)
10 (67%)
Nurse
7 (70%)
3 (30%)
0 (0%)
Doctor
3 (20%)
6 (40%)
6 (40%)
Developing SOs is too time consuming
Supervising SOs is a big medico legal risk to the
gp
When considering the perceived barriers to standing order care, comments from
participants made in the text boxes on the questionnaire suggested that the
development of good relationships, time required in development the need for
supporting education and infrastructures, along with the range of standing orders
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available to participants and sometimes reluctance to work with standing orders were
issues.
Standing orders require good relationships:
“I think if set up properly and you have faith in your nurse's abilities they are not a
problem.”(DR)
“The GP who signs off on the SO will only do so where there is a good collegial
relationship with the nurse. The nurse I work with using SO is more careful than
many GP locums I have worked with. They are no threat, the nurse and I discuss
patients as equal colleagues and often have a shared part of a consultation - very
powerful and supporting to the patient.”(DR)
“When working with multiple doctors there can be confusion with different personal
drug preferences but equally can work well in some situations.” (Nr)
Standing orders take up time:
“In the beginning there is a period where more time is spent with the nurse, but after
1-2 years it is a lot easier. I have been working with the two nurses in the practice for
5 years. Setting up SO can be time consuming but there are a lot of resources
available now that can support the process.” (DR)
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“In our practice we support nurses using SO by perusing their cases within 48hrs(if
they have been on at the weekend). During the week , if they are seeing unscheduled
care patients, I am asked to check so takes time out of my day and can be intrusive.
On the whole it works really well.” (DR)
There are problems with “Ring fencing time to write, develop, review, negotiate
Standing Orders on an ongoing basis.” (Nr)
“Daily review and timeframes for review not feasible in isolated nurse led health
services.” (Nr)
“Freeing up doctor time is not what I see” (Nr)
““Take time to formulate and review against evidence based best practice, but once in
place easy to execute.” (Nr)
“GP would not allow staff to issue SO if he didn’t feel they were competent” (Nr)
"GP/PN relationship needs to be secure, with confidence in skills. PN is accountable
for their own actions and individuals need to feel secure in their scope of practice"
(Nr)
“Back up telephone essential for us as our nurses work alone e.g. checking dosage of
adrenaline in the event of presentation with anaphylaxis. Dr ***** signs off on our
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Standing Orders, she has helped us develop the Standing Orders they are not
implemented until all the parties are in agreement with the content.” (Nr)
Standing orders need supporting education and skills
“All nurses who work with our standing orders are very competent to do so by
maintaining their skill and knowledge base at highest levels and ongoing education.
(Nr)
“Ongoing post grad education needs to be accessible." (Nr)
“Risk of assuming knowledge, there are no established national competencies to
ensure a nurse can follow Standing orders based on adequate health assessment, this is
left to individual doctors.”(Nr)
“Standing orders work well when staff have advanced knowledge in pathophysiology,
pharmacology and assessment skills. Patients do not always present with textbook
symptoms and this causes some issues with standing orders” (Nr)
“I.. would see extension of services through Standing Orders as minimal, as much
more education involves health assessment, history taking, physical exam,
pharmacology before blindly following standing orders.”(Nr)
The quality and scope of Standing orders can be a problem:
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“Often individual practitioner preference and not evidence based.” (Nr)
“Often too prescriptive and dont meet the needs of a noteable proportion of
presentations ie a lack of a comprehensive approach.” (Nr)
“Often too prescriptive without allowing for grays.” (Nr)
“Lack of pharmacies locally reducing access to over the counter medicines, Standing
Orders don’t cover these.” (Nr)
There is a need for infrastructure support:
“Must have adequate stores of all possible medications on site as not able to access
from a pharmacy.” (Nr)
“Often not supported by medical backup just to review a case to ensure no other
potential pathology prior to dispensing. Still need access to medical support.” (Nr)
Nurses do not necessarily want to extend their practice.
“Not all nurses want to extend expand scope into standing orders and this needs to be
respected” (Nr)
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“In our practice there has been mixed feelings particularly between nurses over the
wisdom of the step. It has increased tension a little between those who embrace the
concept and those who are a little more cautious. “ (Dr)
Benefits of Standing Order Care.
There was broad concurrence between doctors and nurses responding to the survey
around statements describing some of the perceived benefits of utilizing standing
orders. Respondents agree standing orders may free up time, are a way of fully
utilizing skills of the team, provide improved access for patients in a way that is safe
both for staff and patients. GPs were less likely to respond positively to the statement
“standing orders provide cheaper care for patients.” (table 4).
Table 4 Responses to Statements about the Benefits of Standing Orders.
SOs free up doctor time
Agree
N
Disagree
3
Nurse
1 (10%)
(30%)
6 (60%)
4
Doctor
1 (7%)
(27%)
10 (67%)
SOs allow best use of the skills of staff
1
Nurse
0 (0%)
(10%)
9 (90%)
Doctor
1(7%)
4
10 (67%)
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(27%)
SOs provide better access to patients for care
Nurse
0 (0%)
0 (0%) 10(100%)
3
Doctor
2 (13%)
(20%)
10 (67%)
SOs provide cheaper care for patients
4
Nurse
0(0%)
(40%)
6 (60%)
9
Doctor
3 (20%)
(60%)
3 (20%)
SOs provide safe care for patients
4
Nurse
0 (0%)
(40%)
6 (60%)
2
Doctor
3 (20%)
(13%)
10 (67%)
0 (0%)
9 (90%)
SOs provide a safe way for non prescribing staff to extend their services
Nurse
1 (10%)
2
Doctor
1 (7%)
(13%)
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When considering the perceived benefits to standing order care, comments from
participants made in the text boxes on the questionnaire suggested that working under
standing orders can be helpful in sharing workload across a team, a satisfying
extension to nursing practice, and improve access to service for patients.
Standing orders can be part of a solution for workforce issues.
"New Zealand has failed abysmally to keep its level of medical graduates up to that
needed by a growing population. It has 3 options - train more doctors, ???
substantially more and meet overseas pay and conditions standards - add suitably
trained nurses and SOs to existing doctors - remain as the beggar with the bowl
outside the international medical graduate market.” (Dr)
“certainly improves the on call situation for rural gps.” (Dr)
Standing orders improve job satisfaction for nurses.
“Satisfaction in extended work role for nurses” (Dr)
“This is a fantastic opportunity for nurses to gain more autonomy with support from
their medical colleague” (Dr)
"It encourages practice nurses to extend their practice, which is a good thing.” (Nr)
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Standing orders improve the quality of nursing practice.
“We are a nurse led PHC service (rural) without the services of a visiting GP. SO
ensures accountability and rationale for practice. So defines scope of practice e.g.
distinguishes RNs from NPs with prescribing rights. SO instills reflective practice as
is signed off by a GP located in the city who does not know some of the nurse or
patients.” (Nr)
“Increased nursing responsibility and recognition of need to be knowledgeable and
responsible for nursing decisions whether that is in following standing orders.” (Nr)
“Enables RN to work collaboratively in extended roles” (Nr)
Standing orders improve teamwork.
“Promotion of interdisciplinary collaborative care particularly in reviewing SOs and
brainstorming ideas and knowledge This can only benefit the patient” (Nr)
“Increased respect and individual contributions to health care, increased trust.” (Nr)
“I think they represent a movement in a change affecting practices whereby care is
shared in teams which utilize safe ways to use peoples skills” (Dr)
Standing orders improve access for patients.
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“Patients needs met quickly without waiting for a GP appointment.” (Nr)
“Standing orders increase access to timely healthcare for this community as there is
no GP preventing many hospital admissions or even need to see GP.” (Nr)
“We work as PHC nurse led nurses in a rural area where there is no GP, however we
use SOs which are signed off by a GP located in town (1 hour away) SOs have been
very beneficial to be able to offer patients an extension of the service we offer and
ensures the nurses work through a process ensuring safety.” (Nr)
“the advantages of SOs allow access to timely and appropriate primary health care
when the GP is difficult to access - either through absence, distance, time. This
hopefully prevents , reduces the risk of common presentations and more serious
presentations leading to deleterious outcomes for patients.” (Nr)
“Increased sharing of health care leads to greater opportunities for health promotion
and recognition of other health determinants.” (Nr)
Limitations of this study:
The findings of this paper cannot represent opinion of the primary care sector in New
Zealand to standing order use.
The survey tool used was not validated and responses were sought from a very small
sample of selected practices, compromising the reliability of findings which can only
be described in terms of the evoked responses from participants. The question design
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was emotive and tends to lead to responses biased to one extreme or another of
opinion.
Analysis of the qualitative data did not include any respondent validation or
triangulation although verbatim quotes are provided in data presentation, analysis of
the data is subject to observer bias without any other form of control.
This paper could be used as a basis for further study through a series of focus groups
across the sector designed to collect qualitative data to a point of saturation.
Discussion :
A number of provider groups have been able to prescribe independently from medical
practitioners for some years including midwives, dentists, and nurses. In isolated rural
settings the Rural Nurse Specialist role has been developed and there is a growing
number of Nurse Practitioners, 35 in July 2007 and growing monthly, but the
extensive education, supervision and legislative requirements needed to ensure safe
independent prescribing of the wide range of medications available in General
Practice limits the number of nurse practitioners who are able to adopt this scope of
practice.
Although Laurant et al in a systematic review of studies where nurses substitute for
doctors in caring for patients[8] show that “appropriately trained nurses can produce
as high quality care as primary care doctors and achieve as good health outcomes for
patients “, nurses do not necessarily value this role,[9, 10] and where nurses are able
to prescribe to a formulary they may not do so because the formulary medicines are
limited in scope or not valued as part of the service [11] or they may lack confidence
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and rather prescribe using standing orders which have the institutional support of
medical colleagues[12].
In New Zealand we know that about a quarter of patients who attend General
Practices also see a practice nurse, as identified by Lightfoot et al in their survey of a
sample of patient encounters in the Waikato taken from 4 weeks over the year 1991 –
1992. [13]
When patients see the practice nurse alone they tend to be seeing them for follow up,
asymptomatic issues, or single issues with limited diagnostic uncertainty, which may
be suitable for standing order care.
GPs are prepared to delegate responsibility within the practice team; as described by
Jenkins-Clarke et al 17% of total consultations and around 40% of the content of the
individual consultations could be delegated to others. The willingness of patients to
see other members of staff was addressed in this study and was not found to be an
issue. [14]
Respondents to our survey raised concerns about the need for good relationships to
support standing orders, the ambivalence that doctor respondents expressed in the
survey reflects the responsibility felt by them for patient care.
The Medical Council of New Zealand states that the medical practitioner remains
responsible for the care of the patient whose care is delegated to another, and that it is
the medical professionals responsibility to ensure that the person who is delegated to
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care for the patient is competent and has enough information about the patient and the
treatment to work safely[43].
The intention of Standing Order legislation is to empower health professionals to
administer medications, they are not an order that requires that medication is
administered, this ensures that the non prescribing provider has to use their judgement
and training when working with standing orders[1] and that the responsibility for the
use of Standing Orders is shared between providers.
Another theme that emerged from the survey as a barrier was that of time required in
development the need for supporting education and infrastructures
Standing orders are recommended to be developed by the people who are to
administer them, this is the best way that they can be learned and adapted to local
needs, this also ensures everyone on the team is aware of the circumstance in which
the medication can be administered. This is a necessary but time consuming task.
Each standing order use has to be ‘signed off’ by the prescribing practitioner “within a
reasonable period of time” – the legislation allows this flexibility which means the
time before sign off can be determined by the availability of staff. It does involve
work, and is a necessary safety mechanism.
In an acknowledgement of the difficulty of ensuring each individual case was ‘signed
off’ legislative change that would allow ‘random review’ or ‘monthly review’ of cases
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was proposed in 2006 but passage of the bill allowing this was delayed in
parliamentary processes.
One of the hopes for shared care and extending nursing roles in primary care is that it
will free up doctors to care for more complicated patients but in a randomized before
and after trial Laurant et al looking at the effect on General Practitioner workload of
introducing nurse practitioners working with patients with chronic obstructive
pulmonary disease, asthma, dementia, or cancer[44] there was no significant effect on
perceived measures of workload, in terms of available time, job satisfaction,
inappropriate demands of patients or perceived cost benefits, and no change in
General Practitioner workload resulting from nurse practitioner work.
Comments from providers in our survey suggest some anxiety about the safe use of
standing orders. A review of the literature around standing order use did not show any
safety concerns[2].
It is important that all providers do work within the parameters of the protocols that
underpin standing order use, Watkins and colleagues found in a study of hypertensive
patients who had access to either nurses or GPs working to an agreed protocol that
more experienced nurses tended to retain patients under their own care rather than
referring on to the GP. [15]It is reassuring that over the 16 months studied there was
no statistical difference in the outcomes in any group of patients.
It is also reassuring to note that in 6 years of using standing orders an internet search
of case reports on the Health and Disability Commissioner website reveals no reports
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of concern, and that in comments in a letter to the Ministry of Health the
Commissioner is broadly supportive of their use[45] as a means of providing “an
effective way of ensuring accessibility of medicines and continuity of care .“
There are no reported ‘near miss’ events in a shared internet based Wiki site dedicated
to Standing Order utilization in New Zealand involving over 40 practitioners
interested in Standing Order use (author personal communication January 2009) and
in 7 years of standing order use in the authors own practice there has never been a
medical error, complaint or patient concern raised regarding the use of standing orders
within the practice team.
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Conclusion :
Further study into the use of standing orders is required to determine the nature of
practices currently using standing orders and to further explore the barriers and
benefits of their use, these studies could take the form of a questionnaire applied to a
representative random selection of practices and a series of focus groups involving
staff from practices that use and that do not use standing orders.
The literature review suggests that standing order use in primary care is safe, and
acceptable to patients. Standing order care has been shown to come at a lower cost to
the health system in the UK, but without statistical significance, further study is
warranted on the cost to the health system of standing order care.
The report on standing order use in one practice shows that standing orders can be
used across a variety of conditions, and the survey and questionnaire suggest a wide
range of standing orders is currently in use in New Zealand across a spectrum of
practices both urban and rural.
Findings from the questionnaire suggest that barriers to the use of standing orders
include concerns about responsibility, time involved in training and development and
safety, but that benefits accrue in the form of better patient access to services and
extension of the nurses role within the primary health care team.
Working with standing orders requires good relationships between primary care team
members, they take time to develop and require the implementation of appropriate
education and development of adequate skills for safe and confident implementation.
83
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Primary care teams need to develop standing orders that have sufficient scope to be
useful and to have the infrastructure to enable medication to be received by the
patient. Teams need to acknowledge and respect that not all members will want to
work with standing orders.
Standing orders can however be part of the solution to workforce pressures, they
improve job satisfaction for nurses and whilst improving access to care for patients
can also improve the quality of nursing practice.
Standing orders can be an agent for change and provide structure for an improvement
in multidisciplinary team work in primary care, it can be argued that the development
of such teamwork is one of the reasons nurses in New Zealand stay working in rural
practice {Murrell-McMillan, 2006 #5977}
The development of a nationally approved cross sector process for producing standing
orders, based on best practice guidelines and backed with clear protocols, that could
be adapted for individual practice and provider circumstances, would address some of
the issues raised by participants in the survey, and strengthen the use of standing
orders in primary care in New Zealand.
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Appendix 1 :
Papers identified for literature review :
Title
Authors
Method
Intervention
Outcomes
Participants
Included / Not included
Title
Authors
Method
Intervention
Outcomes
Participants
Included / Not included
Title
Authors
Method
Intervention
A comparative study of nursing
home resident outcomes between
care provided by nurse
practitioners/physicians versus
physicians only.[46]
Aigner, M. J. Drew,S. Phipps, J.
Retrospective chart review
Nurse practitioner/physician team
vs. physician alone
Service utilization.
Randomly selected patients from 8
rest homes in Texas
Not included
Literature review. Study compares
performance of nurse practitioners
and physicians”... Mundinger MO,
Kane RL, Lenz ER, Totten AM,
Tsai WY, Cleary PD et al (2000).
Primary care outcomes in patients
treated by nurse practitioners or
physicians: a randomized trial. [47]
Brady MA
Review article
Nil
Nil
Nil
Not included
A meta-analysis of nurse
practitioners and nurse midwives in
primary care[48]
Brown, S. A. Grimes, D. E.
A meta analysis of research papers
comparing nurse practitioner and
nurse midwife care with physician
only care.
Studies where nurse practitioners
and nurse managers substitute for
85
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Outcomes
Participants
Included / Not included
Authors
Title
Method
Intervention
Outcomes
Participants
Included / Not included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not included
doctors
33 outcome measures – patients
were more compliant with
treatments provided by NPs
equivalent outcomes in randomised
trials, NMs less use of intervention
and technology.
NPs NMs Physicians
Not included
Bryans, M. Keady,J. Turner,S.
Wilcock, J. Downs, M. Iliffe, S.
An exploratory survey into primary
care nurses and dementia care[49]
Questionnaire pre and post
intervention
Educational intervention around
dementia care
Confidence measures, knowledge
pre and post
Primary care nurses
Not included
Brydon, M.
The effectiveness of a peripatetic
allergy nurse practitioner service in
managing atopic allergy in general
practice-a pilot study[50]
A postal questionnaire survey of 53
allergy patients concurrently with a
survey of the patients' case records.
A specialist allergy nurse
consultation
Symptom improvement and
reduction in allergy related general
practitioner consultations and
prescribed medication.
53 patients identified with allergies
in 3 GPs in the UK
Not Included
86
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Author
Title
Method
Intervention
Outcomes
Participants
Included/ not included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Chafetz, L. Collins-Bride, G. M.
White, M.
A nursing faculty practice for the
severely mentally ill: merging
practice with research[51]
Service report
Nil
Nil
Nil
Not included
Coulthard, M.G. Vernon, S.J.
Lambert, H.J. Matthews, J.N.S.
A nurse led education and direct
access service for the management
of urinary tract infections in
children: prospective controlled
trial.[52]
Prospective cluster randomised trial
Provision of a nurse led direct
access service to children with uti
no prescriptions
Rate and quality of diagnosis of
urinary tract infection, use of
prophylactic antibiotics,
convenience for families, and the
number of infants with
vesicoureteric reflux in whom renal
scarring may have been prevented
346 GPs 100,000 children
Not included
Cox,C. Jones, M.
An evaluation of the management
of patients with sore throats by
practice nurses and GPs. [53]
An observational study
Nurses assessing patients with sore
throats and providing care
including prescriptions
Return rates, patient satisfaction ,
use of abs, use of tests
Patients attending one practice with
87
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Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
sore throats
Not an RCT not included
Donald, F.C. McCurdy, C.
Review: nurse practitioner primary
care improves patient satisfaction
and quality of care with no
difference in health outcomes [54]
Systematic review
Nil
Nurse practitioner primary care at
first point of contact improves
patient satisfaction and quality of
care compared with physician care,
with no difference in health
outcomes. Nurse practitioners also
had longer consultation times and
did more investigations.
NPs
Not included
Fairall, L. R. Zwarenstein, M.
Bateman, E. D. Bachmann, M.
Lombard, C. Majara, B.
P.Joubert,G. English, R. G.
Bheekie, A. Van Rensburg, D.
Mayers, P. Peters,A. C. Chapman,
R. D.
Effect of educational outreach to
nurses on tuberculosis case
detection and primary care of
respiratory illness: [55]
pragmatic cluster randomised
controlled trial
Education provision to nurse
practitioners working in South
African clinics
Comparison of rates of detection,
investigation and management of
TB comparing intervention clinics
and non intervention clinics
40 clinics
Not included
88
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Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Fitzmaurice, D. A. Hobbs, F. D.
Murray, E. T. Holder, R. L. Allan,
T. F. Rose, P. E.
Oral anticoagulation management
in primary care with the use of
computerized decision support and
near-patient testing[56]
a randomized, controlled trial
Nurse led clinic with electronic
decision support compared with
hospital out patient care
efficacy, cost-effectiveness, and
safety
12 practices in UK
Not included
Gensichen, J. Torge, M. Peitz, M.
Wendt-Hermainski, H. Beyer, M.
Rosemann, T. Krauth, C. Raspe,H.
Aldenhoff, J.B. Gerlach, F.M.
Case management for the treatment
of patients with major depression in
general practices--rationale, design
and conduct of a cluster
randomized controlled trial-PRoMPT (PRimary care
Monitoring for depressive Patient's
Trial) -study protocol[57]
Randomly selected practices
Severely depressed patients have a
nurse support telephone
intervention
Depression scores, patient
satisfaction
Depressed patients
Not included
Gilbody, S. Whitty, P.
Improving the recognition and
management of depression in
primary care[58]
Journal article
89
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Intervention
Outcomes
Participants
Included / Not Included
Nil
Nil
Nil
Not included
Author
Title
Gilbody, S. Bower, P. Whitty, P.
Costs and consequences of
enhanced primary care for
depression: Systematic review of
randomised economic
evaluations[59]
Systematic review of costs of
collaborative care interventions in
treatment of depression
Nil
Increased cost but improved quality
of care
Psychologists / GPs
Not included
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Gilbody, S. Whitty, P. Grimshaw,
J. Thomas, R.
Educational and organizational
interventions to improve the
management of depression in
primary care: a systematic
review[60]
Systematic review
Nil
Review of interventions
Nil
Not included
Gill, J. M. Reese, C. L. Diamond, J.
J.
Disagreement among health care
professionals about the urgent care
needs of emergency department
patients[61]
Retrospective chart review
comparing ratings of urgency
between emergency nurses,
emergency physicians and GPs.
90
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Intervention
Outcomes
Participants
Included / Not Included
Nil
Assessment of urgency varied
Nurses and doctors
Not included
Author
Griffiths, C. Foster, G. Barnes, N.
Eldridge, S. Tate, H. Begum, S.
Wiggins, M. Dawson,
C.Livingstone, A.E.Chambers,
M.Coats, T.Harris, R.Feder, G.S.
Specialist nurse intervention to
reduce unscheduled asthma care in
a deprived multiethnic area: the east
London randomised controlled trial
for high risk asthma[27]
Cluster randomised controlled trial.
Nurse led asthma care including
prescription of corticosteroids and
alteration of dose according to
guidelines
Percentage of participants receiving
unscheduled care for acute asthma
over one year and time to first
unscheduled attendance
44 general practices in two
boroughs in east London.324
people aged 4-60 years admitted to
or attending hospital or the general
practitioner out of hours service
with acute asthma;
Included
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Halcomb, E. Davidson, P.Daly, J.
Yallop, J. Tofler, G.
Australian nurses in general
practice based heart failure
management: implications for
innovative collaborative
practice[62]
Literature review of nursing
interventions in heart failure
Nil
Paucity of literature
91
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Participants
Included / Not Included
Nurse practitioners
Not included
Author
Hildebrandt, E. Baisch, M.J.
Lundeen, S.P. Bell-Calvin, J.
Kelber, S.
Eleven years of primary health care
delivery in an academic nursing
center[63]
retrospective review of
computerized client record data.
Nil
Audit of work in a nurse run clinic
Patients over 11 yrs
Not included
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Hollinghurst, S. Horrocks, S.
Anderson, E. Salisbury, C.
Comparing the cost of nurse
practitioners and GPs in primary
care: modelling economic data
from randomised trials[64]
Synthesis of data from 2
randomised trials with cost analysis
Nil
NP costs are higher than GP costs
Nil
Not included
Hollis, J. F. Lichtenstein, E. Vogt,
T. M. Stevens, V. J. Biglan, A.
Nurse-assisted counseling for
smokers in primary care[65]
Randomised Controlled Trial
Nurse led counseling intervention
nil prescribing
Involving nurses in counseling
smokers reduces physician burden,
makes counseling more likely, and
significantly increases cessation
rates compared with brief physician
advice alone.
Smokers primary care
92
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Included / Not Included
Not included
Author
Horrocks, S. Anderson, E.
Salisbury, C.
Systematic review of whether nurse
practitioners working in primary
care can provide equivalent care to
doctors[66]
Systematic review
11 trials 2 3 observational studies
Patients more satisfied, equivalent
health outcomes , nurses gave
longer time and more investigations
, no diff in prescriptions, return
rates or referrals
Systematic review
Not included
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Jansen, Aaltje P. D. van Hout, H. P.
J. van Marwijk, H. W. J. Nijpels, G.
de Bruijne, M.C. Bosmans, J.E.
Pot, AM. Stalman, W. A. B.
Cost-effectiveness of casemanagement by district nurses
among primary informal caregivers
of older adults with dementia
symptoms and the older adults who
receive informal care: design of a
randomized controlled trial[67]
Description of a proposed RCT
Nurse case management
Economic outcomes and caregiver
assessment of confidence
Not clear
Not included
Jarman, B. Hurwitz, B. Cook, A.
Bajekal, M. Lee, A.
Effects of community based nurses
specialising in Parkinson's disease
on health outcome and costs:
randomised controlled trial[68]
RCT
93
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Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
No prescription. Nurse specialists
in Parkinson's disease had little
effect on the clinical condition of
patients, but they did improve their
patients' sense of wellbeing, with
no increase in patients' healthcare
costs.
Survival, stand-up test, dot in
square test, bone fracture, global
health question, PDQ-39, Euroqol,
and healthcare costs.
38 general practices in UK 1859
patients
Not included
Kang, R. Barnard, K. Oshio, S.
Description of the clinical practice
of advanced practice nurses in
family-centered early intervention
in two rural settings[69]
Review of notes and description of
practice
Nil
Nil
Nil
Not included
Kinnersley, P.
Learning curve. Who should see
'extras'?[70]
Journal article
Nil
Nil
Nil
Not included
Kinnersley, P. Anderson, E. Parry,
K.Clement, J. Archard, L. Turton,
P. Stainthorpe, A.Fraser, A.Butler,
C.C. Rogers, C.
Randomised controlled trial of
nurse practitioner versus general
practitioner care for patients
94
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
requesting "same day"
consultations in primary care[71]
RCT comparing nurse with GP care
Nurse vs. doctor care not working
to protocols
Patient satisfaction, resolution of
symptoms and concerns, care
provided (prescriptions,
investigations, referrals, recall, and
length of consultation), information
provided to patients, and patients'
intentions for seeking care in the
future
10 general practices in south Wales
and south west England. Subjects:
1368 patients requesting same day
consultations.
Included
Kitson, C.
Nurse led education plus direct
access to imaging improved
diagnosis and management of
urinary tract infections in
children[72]
cluster randomised controlled trial
44 general practices were allocated
to a NP led intervention (NLI)
(n=55 800 children and 185
physicians) and 44 to usual care
(UC) (n=51 300 children and 161
physicians) NP organized imaging,
reviewed the results with a
paediatric nephrologist, and
informed the physician and family
of normal test results ( not
prescribing )
Nurse led education plus direct
access to imaging improved the rate
of paediatric diagnosis and
management of urinary tract
infections in general practice.
88 general practices 107 100
95
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Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
children who were followed up for
incidence of UTIs.,
Not included
Lamper-Linden, C.Goetz-Kulas,
J.Lake, R.
Developing ambulatory care
clinics: nurse practitioners as
primary providers[73]
Journal article describing practice
Nil
Nil
Nil
Not included
Langham, S.Thorogood,
M.Normand, C.Muir, J.Jones,
L.Fowler, G.
Costs and cost effectiveness of
health checks conducted by nurses
in primary care: the Oxcheck
study[74]
Description of service and cost
analysis
Health check conducted by nurse,
with health education and follow up
according to degree of risk.
Cost of health check programme;
cost per 1% reduction in coronary
risk.
-Five general practices ,2205
patients men and women aged 3564 years.
Not included
Author
Laurant, M. G. H. Hermens, R. P. M.
G. Braspenning, J. C. C. Sibbald, B.
Grol, R. P. T. M.
Title
Impact of nurse practitioners on
workload of general practitioners:
randomised controlled trial[44]
96
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
RCT
48 general practitioner - Five nurses
were randomly allocated to general
practitioners to undertake specific
elements of care according to
agreed guidelines. The control
group received no nurse.
Objective workload, derived from
28 day diaries, included the number
of contacts per day for each of three
conditions (chronic obstructive
pulmonary disease or asthma,
dementia, cancer), by type of
consultation (in practice, telephone,
home visit), and by time of day
(surgery hours, out of hours).
Subjective workload was measured
by using a validated questionnaire.
Outcomes were measured six
months before and 18 months after
the intervention.
48 GP practices
Not Included - not prescribing
Participants
Included / Not Included
Lee, T. Ko, Il-Sun Jeong, S. H.
Is an expanded nurse role
economically viable?[75]
Retrospective review of self
assessment of services
Questionnaire
Costs were lowered by community
health workers
Korean Community Health workers
Not included
Author
Lyles, JS. Hodges, A. Collins, C.
Method
Intervention
Outcomes
Lein, C. Given, CW. Given, B.
Title
Using nurse practitioners to
implement an intervention in
primary care for high utilizing
97
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Method
Intervention
Outcomes
Participants
Included / Not Included
patients with medically unexplained
symptoms[76]
NP case managed 101 patients with
medically unexplained symptoms
and outcomes were compared to
usual care
NP substituted for doctors
A description of the process, no
comparisons actually made
101 participants 102 controls
Not included
Author
Moher, M. Yudkin, P. Wright, L.
Turner, R. Fuller, A. Schofield, T.
Title
Cluster randomized controlled trial
to compare three methods of
promoting secondary prevention of
coronary heart disease in primary
care [26]
Recall to GP or to nurse working to
agreed protocol, or usual care
NP working to protocol
Measure of medication use,
adequate screening documentation (
BP / Chol )
All GP s in a county in UK
Included
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Morris, E.J.
Abstracts from the literature
commentary on primary outcomes
in patients treated by NP or
physicians [77]
Article
Nil
Nil
Nil
Not included
Mundinger, M.O.
Primary Care Outcomes in patients
treated by NP or primary care
physicians [78]
98
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Method
Intervention
Outcomes
Participants
Included / Not Included
RCT
NP substituting for a GP
Pt satisfaction, clinical parameters
(DM asthma BP), service
utilization were all similar
1316 people without a primary care
provider randomized to NP or Gp
care
Not included
Author
Neff, D.F. Mahama, N. Mohar, DRH.
Kinion, E.
Title
Nursing care delivered at academic
community based nurse managed
centre [79]
Description
Nil
Nil
Patients attending clinic
Not Included
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Norg, RJC. van de Beek, K. Portegijs,
PJM. van Schayck, CPO. Knottnerus,
JA.
Title
Included / Not Included
The effectiveness of a treatment
protocol for male lower urinary
tract infection in GP : a practical
randomized controlled trial[80]
RCT comparing GP practices with
protocol vs. those without
Expert based protocol administered
by GPs
No significant difference
14 GP clinics in Netherlands and
pts
Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Ochs
Study touts nursing quality[81]
News article
Nil
Nil
Nil
Not included
Method
Intervention
Outcomes
Participants
99
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Offredy
The application of decision making
concepts by NP in GP[82]
A retrospective study of NP
behaviour
A qualitative study
Decision making in clinical settings
is a complicated process.
Nurse practitioners
Not Included
Palmer RH
An RCT of quality assurance in 16
ambulatory clinic s [83]
Crossover RCT
Quality assurance cycle
Some tasks improved in teams
using quality assurance cycles
16 primary care practices ( 8 GP 8
Paediatric)
Not included
Author
Title
Price MJ
Method
Intervention
Outcomes
Participants
Included / Not Included
Commentary on another paper
Nil
Nil
Nil
Not included
Author
Raftery, JP. Yao, GL. Murchie, P.
Campbell, NC. Ritchie, LD.
Title
Cost effectiveness of nurse led
secondary prevention clinics for
coronary heart disease in primary
care: follow up of a randomized
A nurse-coordinated intervention for
primary care patients with non-insulindependent diabetes mellitus: impact
on glycemic control and healthrelated quality of life... commentary
on Weinberger M, Kirkman S, Samsa
GP et al. [84]
100
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Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
controlled trial [85]
Practices randomized and
compared across UK county
Nurse led intervention clinic
working to agreed protocols
Improved mortality, min inc cost
NPs and GPs
Not Included – not prescribing
Ridsdale, L.
Feasibility and effects of nurse run
clinics for patients with epilepsy in
GP : RCT [86]
Description of nurse run clinics and
audit of attendance comparing
usual care and nurse care
Nurse led intervention
Patient satisfaction , recording of
information
251 people randomized to nurse
clinic or usual care
Not included
Robson, J. Boomla, K. Fitzpatrick,
S. Jewell, AJ. Taylor, J. Self, J.
Using nurses for preventative
activities with computer assisted
follow up: a randomized controlled
trial [87]
Randomised controlled trial.
Health promotion nurse and GP vs.
GP alone care.
Recording and follow up of blood
pressure and cervical smears after
three years. Recording of smoking,
family history of ischaemic heart
disease, and serum cholesterol
concentrations were also examined.
Intervention increased recording of
outcomes.
Participants
Single general practice 3206 men and
women aged 30-64 registered with
the practice.
Included / Not Included
Not Included
101
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Running, A. Kipp, C. Mercer, V.
Prescriptive patterns of nurse
practitioners and physicians[88]
Retrospective notes review
Nil
One hundred charts were reviewed
for each condition for a total of 400
charts (200 of the charts were for NP
providers, and 200 were for physician
providers)
Treatment of common conditions
was reviewed
Not included
Sanders, D. Fowler, G. Mant, D.
Fuller, A. Jones, L. Marzillier, J.
Randomised controlled trial of anti
smoking advice by nurses in
General Practice[89]
Pts randomized to nurse clinic
health check or not
Nurse provides variety of advice,
not prescription
11% one year success rate, no
significant difference in
intervention group.
Practices in Oxford UK
Not included – not prescription
based
Santry, H. Clark, DJ.
Primary care groups: nurses on
board[90]
Journal article
Nil
Nil
Nil
Not included
Saur, CD. Harpole, LH. Steffens,
DC. Fulcher, CD. Porterfiled, Y.
Haverkamp, R.
102
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Treating depression in primary care
: an innovative role for mental
health nurses.[18]
Case studies
Nil
Nil
Nil
Not included
Schreuders, B. Van Oppen, P. Van
Marwick, HWJ. Smit, JH. Stalman,
JB.
Frequent attenders in general
practice: problem solving treatment
provided by nurses[91]
Description of a trail protocol
comparing usual care with problem
solving treatment
Nil
Nil
Nil
Not included
Shum, C. Humphreys, A.Wheeler,
D. Cochrane, M. Skoda, S.
Clement, S.
Nurse management of patients with
minor illnesses in general practice:
multicentre, randomized controlled
trial.[92]
Pts randomized to nurse Or doctor
care
Specialist trained nurse providing
scripts, referring on where required
Consultation satisfaction
questionnaire, length of the
consultation, number of
prescriptions written, rates of
referral to general practitioners,
patient's reported health status,
patient's anticipated behaviour in
seeking health care in future, and
number of patients who returned to
103
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
the surgery, visits to accident and
emergency, and out of hours calls
to doctors.
5 general practices,1815 patients
requesting and offered same day
appointments by receptionists.
Not included – nurses substitute for
GP not protocol driven
Sox, HC.
Independent primary care practice
by nurse practitioners [93]
Book chapter reviewing Mundinger
Nil
Nil
Nil
Not included
Spitzer, WO. Sackett, DL.Sibley,
JC. Roberts, RS. Gent, M. Kergin,
DJ.
The Burlington randomized trial of
the nurse practitioner. a classic
manuscript reprinted in celebration
of 25 years of progress[94]
Paper not available,
a randomized controlled trial
assessing the effects of substituting
nurse practitioners for physicians in
primary-care practice.
Outcomes
Participants
Included / Not Included
Equivalent care outcomes
Nurses substitute for doctors
Not Included
Author
Title
Stothard, A. Brewer, K.
Dramatic improvement in COPD
patient care in nurse led clinic [95]
Journal article
Nil
Nil
Nil
Not included
Method
Intervention
Outcomes
Participants
Included / Not Included
104
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Author
Title
Method
Intervention
Outcomes
Swindle, RW. Rao, JK. Helmy, A.
Plue, L. Zhou, XH. Eckert, GJ.
Integrating clinical nurse specialists
into the treatment of primary care
patients with depression [96]
randomized trial of patients screening
positive for depression
GP care vs. Nurse specialist driven
care
Equivalent clinical outcomes, greater
documentation of depression and a
higher referral rate to mental health
services at 3 months in intervention
group. No difference in the
prescriptions for anti-depressant
medications.
Participants
Included / Not Included
As above
Not included – paper not available
Author
Tornkvist, L. Gardulf, A.
Strender,L.
Effects of pain advisers: district
nurses opinions regarding their own
knowledge, management and
documentation of patients in
chronic pain. [97]
Pain advisers introduced into
certain areas, district nurses
questioned about care of people in
pain
Pain adviser in place or not
In places with pain advisors nurses
felt improved documentation of
pain plans
District nurses
Not included
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Unutzer, J. Katon, W.Callahan, C.
Williams, JW. Hunkeler,
E.Harpole, L.
Collaborative care management of
late life depression in the primary
care setting: a randomized
controlled trial [98]
105
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Primary care population screened
for depression randomized to
intervention or normal care
Psychiatric Nurses and
psychologists applying a suite of
care for depression including
medication, psychological
interventions
3 – 6 – 12 month outcomes
1801 patients
Not included – not practice nurses
involved
Venning, P.Durie, A.Roland, M.
Roberts, C. Leese, B.
RCT comparing cost effectiveness
of general practitioners and nurse
practitioners in primary care. [25]
Pts randomized to GP or NP care
Nurses substituted for doctors
Consultation process (length of
consultation, examinations,
prescriptions, referrals), patient
satisfaction, health status, return
clinic visits over two weeks, and
costs
20 general practices 1716 patients
Included
Participants
Included / Not Included
Vonderheid, S. Pohl, J. Barkauskas,
V. Gift, D. Hughes-Cromwick, P.
Financial performance of academic
nurse managed primary care
centres[99]
Review of financial performance of
6 nurse led clinics in the USA
Nil
Benchmarking of financial
performance
Nurse led clinics
Not included
Author
Wardrope, J. Rothwell, S.
Title
Method
Intervention
Outcomes
106
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Primary care outcomes in patients
treated by nurse practitioners or
physicians. A randomized trial
[100]
A review article of another trial
Nil
Nil
Nil
Not included
Wearden, AJ. Riste, L. Dowrick, C.
Chew-Graham, C. Bentall, RP.
Morriss, RK.
Fatigue intervention by nurses
evaluation – the FINE Trial. A
randomized controlled trial of nurse
led self help treatment for patients
in primary care with chronic fatigue
syndrome: study protocol [101]
Single blind pragmatic randomized
trial
Specially trained nurses applied one
of 2 specific treatment programmes
in patient's home compared to usual
care.
Protocol only
nil
Not included
Winslow, R.
Nurse practitioners patients fare
well in study [102]
Journal article
Nil
Nil
Nil
Not included
Wright, S.
A nurse led clinic and computer
decision support system for
anticoagulation decisions was at
least as effective as a hospital clinic
107
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
[103]
Comment on a paper by
Fitzmaurice
Nil
Nil
Nil
Not included
Yallop, J. Clark, R. Chan, B.
Croucher, J. Wilson, A. Sellar, B.
CHAT – a study of a nurse led
system of care [104]
Journal article
Nil
Nil
Nil
Not included
Greenfield, S. Anderson, H.
Winickoff, RN.
Nurse protocol management of low
back pain-Outcomes, patient
satisfaction and efficiency of
primary care.[105]
Patients randomly assigned to nurse
protocol or usual care
Nurse protocol care
Equivalent clinical and patient
satisfaction outcomes
Walk in patients in GP
Included
Greenfield, S. Friedland, G. Scifers,
S. Rhodes, A. Black, WL.
Komaroff, AL.
Protocol management of dysuria,
urinary frequency, and vaginal
discharge[23]
Randomised controlled trial
Nurse protocol vs. GP care
Equivalent clinical outcomes
Nurses and GPs
Included
108
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Method
Intervention
Outcomes
Participants
Included / Not Included
Author
Title
Greenfield, S. Komaroff, AL.
Anderson, H.
A headache protocol for nurses:
effectiveness and efficiency. [106]
Patients randomly assigned to nurse
or GP care
Nurse protocol vs. GP care
Equivalent clinical outcomes
Nurses and GPs
Included
Fall M, Walters S, Read S, Deverill
M, Lutman M, Milner P
An evaluation of a nurse-led ear
care service in primary care:
benefits and costs.[107]
Prospective observational cohort
study
Nurse led clinic intervention
Equivalent clinical outcomes
Nurse/ GPs
Not included
Rees, M. Butler, C.
Coughs and colds: nurse
management of upper respiratory
tract infection.[108]
Journal article reporting literature
Nil
Nil
Nurses
Not included
Watkins, LO. Wagner, EH.
Nurse practitioner and physician
adherence to standing orders
criteria for consultation or
referral[15]
109
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Method
Intervention
Outcomes
Participants
Included / Not Included
Observational study
Nurses working to protocols
Equivalent clinical outcomes
Nurses / GPs
Not included
110
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Appendix 2
Questionnaire Development:
Questionnaire sent to one Doctor and one Nurse from each practice :
Statement
Strongly
Disagree
Disagree Neutral Agree Strongly
Agree
SOs free up doctor time
SOs allow best use of the
skills of all staff
SOs provide better access to
patients for care
SOs provide cheaper care for
patients
SOs provide safe care for
patients
SOs provide a safe way for
non-prescribing staff to
extend their services
Statement
Strongly
Disagree
Disagree Neutral Agree Strongly
Agree
SOs allow non prescribing
staff to work beyond their
level of competence
111
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
SOs are not acceptable to
patients
SOs decrease the profit that
practices can generate
SOs increase the risk of
medication errors
SOs are a threat to the doctor
patient relationship
SOs need too much
supervision
Developing SOs is time
consuming
Supervising SOs is a medico
legal risk to the GP
The questionnaire was developed after review of the literature had revealed several
common themes , nurses substituting for doctors can be cost effective, acceptable to
patients, and an effective way of delivering chronic and same day care for short term
conditions [8] but it does not necessarily have a positive impact on GP workload [16]
and can take up a lot of nursing time [9]
There is a potential medico-legal risk inherent in working with protocols especially if
all parties do not stick to the protocols[15]
112
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Standing orders need to be relevant and developed by the local teams to be utilized
well [109] this will take time and effort from the whole team. Standing orders are seen
to provide more appropriate services to local patient needs, and a safer medico legal
option than independent prescribing by nurses [110].
Feedback from nurses, doctors and administrators attending a presentation made to
the Rural General Practice Network conference in April 2008 suggested that issues
creating barriers to adoption of standing orders include anxiety about scopes of
practice, reluctance of doctors to develop standing orders due to legal issues and time
constraints, and that doctors are wary of their introduction seeing there is a potential
threat to the doctor patient relationship - if the simple cases are taken out of their
daily work it is in discussion around the simple things that a trusting relationship
develops that allows more complex issues to be discussed.
The questionnaire was trialled and feedback received from two practices, no
modifications were suggested.
In the New Zealand setting where patient’s co-payment is an important aspect to
practice income, a cheaper fee for patients seeing the nurse may be attractive to the
patient but may have an adverse effect on practice income.
113
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
References:
[1]
MoH. Guidelines for the Development and Operation of Standing Orders. In:
Health Mo, ed. 2002.
[2]
Scott-Jones J, Lawrenson R. Doctors and Nurses:Standing Orders in primary
care - a literature review NZFP. 2008 April;35(2):107-11.
[3]
Health Mo. The Primary Health Care Strategy In: Health Mo, ed. 2001.
[4]
NZMA. Closed Books Survey VITAL SIGNS 2007 08 06 2007
[5]
The New Zealand Medical Workforce 2007 New Zealand Medical Council
..
2008.
[6]
Mel Pande M, Fretter J, Stenson A, Webber C, Turner J. Royal New Zealand
College Of General Practitioners Workforce Survey 2005 part 3: General Practitioners
In Urban and Rural New Zealand; 2006.
[7]
Ryall T. Press Release - GP training numbers to increase 4/12/2008. 2008.
[8]
Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B.
Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev.
2005(2):CD001271.
[9]
Fisher R. Relationships in nurse prescribing in district nursing practice in
England: a preliminary investigation. Int J Nurs Pract. 2005 Jun;11(3):102-7.
[10]
Wiles R, Postle K, Steiner A, Walsh B, Southampton NLUCET. Nurse-led
intermediate care: an opportunity to develop enhanced roles for nurses? J Adv Nurs.
2001 Jun;34(6):813-21.
[11]
Hippisley-Cox J, Pringle M, Cater R, Wynn A, Hammersley V, Coupland C.
The use of patient group directions for zanamivir in 2000/2001: Cross-sectional
114
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
survey of primary care organisations in England: Quality in Primary Care. Vol.
11(2)(pp 97-106), 2003. 2003.
[12]
Hall J, Cantrill J, Noyce P. Why don't trained community nurse prescribers
prescribe? J Clin Nurs. 2006 Apr;15(4):403-12.
[13]
Davis P, Lightfoot R, Finn E, Lay-Yee R, Gribben B, McAvoy B. Practice
nurses in the Waikato, 1991-1992: What was their patient mix and pattern of care? .
New Zealand Family Physician. 1999 1999;26:50-4.
[14]
Jenkins-Clarke S, Carr-Hill R, Dixon P. Teams and seams: skill mix in
primary care. J Adv Nurs. 1998 Nov;28(5):1120-6.
[15]
Watkins LO, Wagner EH. Nurse practitioner and physician adherence to
standing orders criteria for consultation or referral. Am J Public Health. 1982
Jan;72(1):22-9.
[16]
Laurant MGH, Hermens RPMG, Braspenning JCC, Sibbald B, Grol RPTM.
Impact of nurse practitioners on workload of general practitioners: randomised
controlled trial. BMJ. 2004 April 17, 2004;328(7445):927-.
[17]
Weinberger M, Kirkman MS, Samsa GP, Shortliffe EA, Landsman PB,
Cowper PA, et al. A nurse-coordinated intervention for primary care patients with
non-insulin-dependent diabetes mellitus: impact on glycemic control and healthrelated quality of life.[see comment]. J Gen Intern Med. 1995 Feb;10(2):59-66.
[18]
Saur CD, Harpole LH, Steffens DC, Fulcher CD, Porterfield Y, Haverkamp R,
et al. Treating depression in primary care: an innovative role for mental health nurses.
Journal of the American Psychiatric Nurses Association 2002 Oct; 8(5): 159-67 (30
ref).
[19]
Spitzer WO, Sackett DL, Sibley JC, Roberts RS, Gent M, Kergin DJ, et al.
1965-1990: 25th anniversary of nurse practitioners. A classic manuscript reprinted in
115
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
celebration of 25 years of progress. The Burlington randomized trial of the nurse
practitioner. 1971-2.[see comment]. J Am Acad Nurse Pract. 1990 Jul-Sep;2(3):93-9.
[20]
Swindle RW, Rao JK, Helmy A, Plue L, Zhou XH, Eckert GJ, et al.
Integrating clinical nurse specialists into the treatment of primary care patients with
depression: International Journal of Psychiatry in Medicine. Vol. 33(1)(pp 17-37),
2003. 2003.
[21]
Greenfield S, Friedland G, Scifers S, Rhodes A, Black WL, Komaroff AL.
Protocol management of dysuria, urinary frequency, and vaginal discharge. J Fam
Pract. 1975 Jun;2(3):179-84.
[22]
Greenfield S, Komaroff AL, Anderson H. A headache protocol for nurses:
effectiveness and efficiency. Arch Intern Med. 1976 October 1, 1976;136(10):1111-6.
[23]
Greenfield S, Friedland G, Scifers S, Rhodes A, Black WL, Komaroff AL.
Protocol management of dysuria, urinary frequency, and vaginal discharge. Ann
Intern Med. 1974 Oct;81(4):452-7.
[24]
Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al.
Randomised controlled trial of nurse practitioner versus general practitioner care for
patients requesting "same day" consultations in primary care.[see comment]. BMJ.
2000 Apr 15;320(7241):1043-8.
[25]
Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled
trial comparing cost effectiveness of general practitioners and nurse practitioners in
primary care.[see comment]. BMJ. 2000 Apr 15;320(7241):1048-53.
[26]
Moher M, Yudkin P, Wright L, Turner R, Fuller A, Schofield T, et al. Cluster
randomised controlled trial to compare three methods of promoting secondary
prevention of coronary heart disease in primary care. BMJ 2001 Jun 2; 322(7298):
1338-42 (16 ref).
116
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
[27]
Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S, et al. Specialist
nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area:
the east London randomised controlled trial for high risk asthma (ELECTRA).[see
comment]. BMJ. 2004 Jan 17;328(7432):144.
[28]
Sackett DL, Scott Richardson W, Rosenberg W, Brian Haynes R. Evidence-
based Medicine How to Practice and Teach EBm: Churchill Livingstone 1997.
[29]
Greenfield S, Anderson H, Winickoff R. Nurse protocol management of low
back pain-Outcomes, patient satisfaction and efficiency of primary care. West J Med.
1975 Nov 123:350-9.
[30]
Sitzia J. How valid and reliable are patient satisfaction data? An analysis of
195 studies. Int J Qual Health Care. 1999 Aug
Aug;11(4):319-28.
[31]
Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al.
Randomised controlled trial of nurse practitioner versus general practitioner care for
patients requesting "same day" consultations in primary care. BMJ. 2000 April 15,
2000;320(7241):1043-8.
[32]
Goedhuys J, Rethans JJ. On the relationship between the efficiency and the
quality of the consultation. A validity study. Fam Pract. 2001 Dec;18(6):592-6.
[33]
Campbell SM, Roland MO, Buetow SA. Defining quality of care. Soc Sci
Med. 2000 Dec;51(11):1611-25.
[34]
Health Mo. Nurse Practitioners in New Zealand 2002.
[35]
New Zealand Guidelines Group [cited; Available from: www.nzgg.org.nz
[36]
New Zealand Medicines and Medical Devices Safety Authority - Medsafe
[cited; Available from: www.medsafe.govt.nz
117
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
[37]
DoH. Report of the Advisory Group in Nurse Prescribing (Crown Report) In:
DoH, ed.: London:DoH 1989.
[38]
Courtenay M. Supplementary prescribing and clinical management plans.
Prim Health Care. 2004 Jun;14(5):18-20. (10 ref).
[39]
Hobson R, Sewell G. Supplementary prescribing by pharmacists in England.
Am J Health Syst Pharm Ajhp. 2006 Feb 1;63(3):244-53. (73 ref).
[40]
Courtenay M, Carey N, Burke J. Independent extended and supplementary
nurse prescribing practice in the UK: a national questionnaire survey. Int J Nurs Stud.
2007 Sep
Sep;44(7):1093-101.
[41]
Latter S, Courtenay M. Effectiveness of nurse prescribing: a review of the
literature.[see comment]. J Clin Nurs. 2004 Jan;13(1):26-32.
[42]
O'Connor T. Nurse prescribing a reality at last. Kai Tiaki Nurs Nz. 2005
Oct;11(9):10-1.
[43]
St George I, ed. Cole's Medical Practice in New Zealand New Zealand
Medical Council 2008
[44]
Laurant MGH, Hermens R, Braspenning JCC, Sibbald B, Grol R. Impact of
nurse practitioners on workload of general practitioners: Randomised controlled trial:
British Medical Journal. Vol. 328(7445)(pp 927-930), 2004.Date of Publication: 17
APR 2004. 2004.
[45]
Paterson R. Review of Policy relating to the Operation of Medicines (Standing
Orders) Regulations 2002: Discussion Document. 2006 22 Nov 2006
[46]
Aigner MJ, Drew S, Phipps J. A comparative study of nursing home resident
outcomes between care provided by nurse practitioners/physicians versus physicians
only.[see comment]. J Am Med Dir Assoc. 2004 Jan-Feb;5(1):16-23.
118
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
[47]
Brady MA. Literature review. Study compares performance of nurse
practitioners and physicians... Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai
WY, Cleary PD et al (2000). Primary care outcomes in patients treated by nurse
practitioners or physicians: a randomized trial. JAMA, 283, 59-68. Journal of
Pediatric Health Care 2000 May-Jun; 14(3): 140-1 (1 ref).
[48]
Brown SA, Grimes DE. A meta-analysis of nurse practitioners and nurse
midwives in primary care. Nurs Res. 1995 Nov-Dec;44(6):332-9.
[49]
Bryans M, Keady J, Turner S, Wilcock J, Downs M, Iliffe S. An exploratory
survey into primary care nurses and dementia care. Br J Nurs. 2003 Sep 25-Oct
8;12(17):1029-37.
[50]
Brydon M. The effectiveness of a peripatetic allergy nurse practitioner service
in managing atopic allergy in general practice--a pilot study. Clin Exp Allergy. 1993
Dec;23(12):1037-44.
[51]
Chafetz L, Collins-Bride GM, White M. A nursing faculty practice for the
severely mentally ill: merging practice with research. Nurs Outlook. 2004 JulAug;52(4):209-14.
[52]
Coulthard MG, Vernon SJ, Lambert HJ, Matthews JNS. A nurse led education
and direct access service for the management of urinary tract infections in children:
prospective controlled trial.[see comment]. BMJ. 2003 Sep 20;327(7416):656.
[53]
Cox C, Jones M. An evaluation of the management of patients with sore
throats by practice nurses and GPs. Br J Gen Pract. 2000 Nov;50(460):872-6.
[54]
Donald FC, McCurdy C. Review: nurse practitioner primary care improves
patient satisfaction and quality of care with no difference in health outcomes.
Evidence-Based Nursing 2002 Oct; 5(4): 121 (2 ref).
119
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
[55]
Fairall LR, Zwarenstein M, Bateman ED, Bachmann M, Lombard C, Majara
BP, et al. Effect of educational outreach to nurses on tuberculosis case detection and
primary care of respiratory illness: pragmatic cluster randomised controlled trial.
BMJ. 2005 Oct 1;331(7519):750-4.
[56]
Fitzmaurice DA, Hobbs FD, Murray ET, Holder RL, Allan TF, Rose PE. Oral
anticoagulation management in primary care with the use of computerized decision
support and near-patient testing: a randomized, controlled trial. Arch Intern Med.
2000 Aug 14-28;160(15):2343-8.
[57]
Gensichen J, Torge M, Peitz M, Wendt-Hermainski H, Beyer M, Rosemann T,
et al. Case management for the treatment of patients with major depression in general
practices--rationale, design and conduct of a cluster randomized controlled trial-PRoMPT (PRimary care Monitoring for depressive Patient's Trial)
[ISRCTN66386086]--study protocol. BMC Public Health. 2005;5:101.
[58]
Gilbody S, Whitty P. Improving the recognition and management of
depression in primary care. Effect Health Care. 2002;7(5):1-11.
[59]
Gilbody S, Bower P, Whitty P. Costs and consequences of enhanced primary
care for depression: Systematic review of randomised economic evaluations: British
Journal of Psychiatry. Vol. 189(OCT.)(pp 297-308), 2006. 2006.
[60]
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational
interventions to improve the management of depression in primary care: a systematic
review. JAMA: Journal of the American Medical Association. 2003 Jun
18;289(23):3145-51.
[61]
Gill JM, Reese CLt, Diamond JJ. Disagreement among health care
professionals about the urgent care needs of emergency department patients.[see
comment]. Annals of Emergency Medicine. 1996 Nov;28(5):474-9.
120
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
[62]
Halcomb E, Davidson P, Daly J, Yallop J, Tofler G. Australian nurses in
general practice based heart failure management: implications for innovative
collaborative practice. Eur J Cardiovasc Nurs. 2004 Jul;3(2):135-47.
[63]
Hildebrandt E, Baisch MJ, Lundeen SP, Bell-Calvin J, Kelber S. Eleven years
of primary health care delivery in an academic nursing center. J Prof Nurs. 2003 SepOct;19(5):279-88.
[64]
Hollinghurst S, Horrocks S, Anderson E, Salisbury C. Comparing the cost of
nurse practitioners and GPs in primary care: modelling economic data from
randomised trials.[see comment]. Br J Gen Pract. 2006 Jul;56(528):530-5.
[65]
Hollis JF, Lichtenstein E, Vogt TM, Stevens VJ, Biglan A. Nurse-assisted
counseling for smokers in primary care. Annals of Internal Medicine 1993 Apr 1;
118(7): 521-5 (36 ref).
[66]
Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse
practitioners working in primary care can provide equivalent care to doctors.[see
comment]. BMJ. 2002 Apr 6;324(7341):819-23.
[67]
Jansen APD, van Hout HPJ, van Marwijk HWJ, Nijpels G, de Bruijne MC,
Bosmans JE, et al. (Cost)-effectiveness of case-management by district nurses among
primary informal caregivers of older adults with dementia symptoms and the older
adults who receive informal care: design of a randomized controlled trial
[ISCRTN83135728]. BMC Public Health. 2005;5:133.
[68]
Jarman B, Hurwitz B, Cook A, Bajekal M, Lee A. Effects of community based
nurses specialising in Parkinson's disease on health outcome and costs: randomised
controlled trial. BMJ. 2002 May 4;324(7345):1072-5.
121
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
[69]
Kang R, Barnard K, Oshio S. Description of the clinical practice of advanced
practice nurses in family-centered early intervention in two rural settings. Public
Health Nurs. 1994 Dec;11(6):376-84.
[70]
Kinnersley P. Learning curve. Who should see 'extras'? Nursing Times 2000
Apr 13-19; 96(15): 42 (2 ref).
[71]
Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al.
Randomised controlled trial of nurse practitioner versus general practitioner care for
patients requesting 'same day' consultations in primary care: British Medical Journal.
Vol. 320(7241)(pp 1043-1048), 2000.Date of Publication: 15 APR 2000. 2000.
[72]
Kitson C. Nurse led education plus direct access to imaging improved
diagnosis and management of urinary tract infections in children. Evidence-Based
Nursing 2004 Jul; 7(3): 73 (1 ref).
[73]
Lamper-Linden C, Goetz-Kulas J, Lake R. Developing ambulatory care
clinics: nurse practitioners as primary providers. J Nurs Adm. 1983 Dec;13(12):11-8.
[74]
Langham S, Thorogood M, Normand C, Muir J, Jones L, Fowler G. Costs and
cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck
study.[see comment]. BMJ. 1996 May 18;312(7041):1265-8.
[75]
Lee T, Ko I-S, Jeong SH. Is an expanded nurse role economically viable? J
Adv Nurs. 2004 Jun;46(5):471-9.
[76]
Lyles JS, Hodges A, Collins C, Lein C, Given CW, Given B, et al. Using
nurse practitioners to implement an intervention in primary care for high-utilizing
patients with medically unexplained symptoms. General Hospital Psychiatry. 2003
Mar-Apr;25(2):63-73.
[77]
Morris EJ. Abstracts from the literature. Professional practice... commentary
on Primary outcomes in patients treated by nurse practitioners or physicians.
122
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai W, Cleary PD et al. JAMA
2000;283:59-68. Journal of WOCN 2000 Sep; 27(5): 26A.
[78]
Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PD, et al.
Primary care outcomes in patients treated by nurse practitioners or physicians: a
randomized trial.[see comment]. Jama. 2000 Jan 5;283(1):59-68.
[79]
Neff DF, Mahama N, Mohar DRH, Kinion E. Nursing care delivered at
academic community-based nurse-managed center. Outcomes Manag. 2003 AprJun;7(2):84-9.
[80]
Norg RJC, van de Beek K, Portegijs PJM, van Schayck CPO, Knottnerus JA.
The effectiveness of a treatment protocol for male lower urinary tract symptoms in
general practice: A practical randomised controlled trial. Br J Gen Pract.
2006;56(533):938-44.
[81]
Ochs R. Study touts nursing quality: practitioners called as effective as
doctors... copyright (C) 2000 Newsday, Inc. Academic Nurse 2000 Spring; 17(1): 22.
[82]
Offredy M. The application of decision making concepts by nurse
practitioners in general practice. J Adv Nurs. 1998 Nov;28(5):988-1000.
[83]
Palmer RH, Louis TA, Hsu LN, Peterson HF, Rothrock JK, Strain R, et al. A
randomized controlled trial of quality assurance in sixteen ambulatory care practices.
Med Care. 1985 Jun;23(6):751-70.
[84]
Price MJ. A nurse-coordinated intervention for primary care patients with non-
insulin-dependent diabetes mellitus: impact on glycemic control and health-related
quality of life... commentary on Weinberger M, Kirkman S, Samsa GP et al. J GEN
INTERN MED 10:59-66, 1995. Diabetes Spectrum 1996; 9(3): 186-8 (8 ref).
[85]
Raftery JP, Yao GL, Murchie P, Campbell NC, Ritchie LD. Cost effectiveness
of nurse led secondary prevention clinics for coronary heart disease in primary care:
123
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
Follow up of a randomised controlled trial: British Medical Journal. Vol.
330(7493)(pp 707-710), 2005.Date of Publication: 26 MAR 2005. 2005.
[86]
Ridsdale L, Robins D, Cryer C, Williams H. Feasibility and effects of nurse
run clinics for patients with epilepsy in general practice: Randomised controlled trial:
British Medical Journal. Vol. 314(7074)(pp 120-122), 1997. 1997.
[87]
Robson J, Boomla K, Fitzpatrick S, Jewell AJ, Taylor J, Self J, et al. Using
nurses for preventive activities with computer assisted follow up: a randomised
controlled trial. BMJ. 1989 Feb 18;298(6671):433-6.
[88]
Running A, Kipp C, Mercer V. Prescriptive patterns of nurse practitioners and
physicians. J Am Acad Nurse Pract. 2006 May;18(5):228-33.
[89]
Sanders D, Fowler G, Mant D, Fuller A, Jones L, Marzillier J. Randomized
controlled trial of anti-smoking advice by nurses in general practice. J R Coll Gen
Pract. 1989 Jul;39(324):273-6.
[90]
Santry H, Clark DJ. Primary care groups: nurses on the board. Nurs Stand.
1999 Oct 20-26;14(5):34-9.
[91]
Schreuders B, van Oppen P, van Marwijk HWJ, Smit JH, Stalman WAB.
Frequent attenders in general practice: problem solving treatment provided by nurses
[ISRCTN51021015]. BMC Fam Pract. 2005 Oct 12;6:42.
[92]
Shum C, Humphreys A, Wheeler D, Cochrane MA, Skoda S, Clement S.
Nurse management of patients with minor illnesses in general practice: multicentre,
randomised controlled trial.[see comment]. BMJ. 2000 Apr 15;320(7241):1038-43.
[93]
Wasson JH, Sauvigne AE, Mogielnicki RP, Frey WG, Sox CH, Gaudette C, et
al. Continuity of outpatient medical care in elderly men. A randomized trial. Jama.
1984 Nov 2;252(17):2413-7.
124
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
[94]
Spitzer WO, Sackett DL, Sibley JC, Roberts RS, Gent M, Kergin DJ, et al.
The Burlington randomized trial of the nurse practitioner... a classic manuscript
reprinted in celebration of 25 years of progress. Journal of the American Academy of
Nurse Practitioners 1990 Jul-Sep; 2(3): 93-9 (30 ref).
[95]
Stothard A, Brewer K. Dramatic improvement in COPD patient care in nurse-
led clinic. Nurs Times. 2001 Jun 14-20;97(24):36-7.
[96]
Swindle RW, Rao JK, Helmy A, Plue L, Zhou XH, Eckert GJ, et al.
Integrating clinical nurse specialists into the treatment of primary care patients with
depression. Int J Psychiatry Med. 2003;33(1):17-37.
[97]
Tornkvist L, Gardulf A, Strender L. Effects of 'pain-advisers': district nurses'
opinions regarding their own knowledge, management and documentation of patients
in chronic pain. Scandinavian Journal of Caring Sciences 2003 Dec; 17(4): 332-8 (34
ref).
[98]
Unutzer J, Katon W, Callahan CM, Williams JW, Jr., Hunkeler E, Harpole L,
et al. Collaborative care management of late-life depression in the primary care
setting: a randomized controlled trial. JAMA: Journal of the American Medical
Association. 2002 Dec 11;288(22):2836-45.
[99]
Vonderheid S, Pohl J, Barkauskas V, Gift D, Hughes-Cromwick P. Financial
performance of academic nurse-managed primary care centers. Nurs Econ. 2003 JulAug;21(4):167-75.
[100] Wardrope J, Rothwell S. Primary care outcomes in patients treated by nurse
practitioners or physicians. A randomized trial. J Accid Emerg Med. 2000
Jul;17(4):290-1.
[101] Wearden AJ, Riste L, Dowrick C, Chew-Graham C, Bentall RP, Morriss RK,
et al. Fatigue Intervention by Nurses Evaluation--the FINE Trial. A randomised
125
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
controlled trial of nurse led self-help treatment for patients in primary care with
chronic fatigue syndrome: study protocol. BMC Med. 2006;4:9.
[102] Winslow R. Nurse practitioners' patients fare well in study... republished with
permission of Dow Jones & Company, Inc. from The Wall Street Journal,
Wednesday, January 5, 2000. Academic Nurse 2000 Spring; 17(1): 20.
[103] Wright S. A nurse led clinic and computer decision support system for
anticoagulation decisions was at least as effective as a hospital clinic... commentary
on Fitzmaurice DA, Hobbs FD, Murray ET, et al. Oral anticoagulation management in
primary care with the use of computerized decision support and near-patient testing: a
randomized, controlled trial. ARCH INTERN MED 2000 Aug 14-28;160:2343-8.
Evidence-Based Nursing 2001 Apr; 4(2): 57 (5 ref).
[104] Yallop J, Clark R, Chan B, Croucher J, Wilson A, Sellar B, et al. CHAT--a
study of a nurse-led system of care. Aust Nurs J. 2006 Oct;14(4):19.
[105] Greenfield S, Anderson H, Winickoff R. Nurse protocol management of low
back pain-Outcomes, patient satisfaction and efficiency of primary care. West J Med
1975 Nov 123:350-9.
[106] Greenfield S, Komaroff AL AH. A headache protocol for nurses: effectiveness
and efficiency. . Arch Intern Med
1976
October 1 1976;136
(10):1111-6.
[107] Fall M, Walters S, Read S, Deverill M, Lutman M, Milner P, et al. An
evaluation of a nurse-led ear care service in primary care: Benefits and costs. 1997.
[108] Rees M, Butler C. Coughs and colds: nurse management of upper respiratory
tract infection. Nurs Stand. 2001 Jun 13-19;15(39):33-5.
126
Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583
[109] Jones PGW. Patient group directions - The Salford primary care experience:
Journal of Clinical Governance. Vol. 10(1)(pp 3-6), 2002. 2002.
[110] Larsen D. Issues affecting the growth of independent prescribing. Nursing
Standard 2004 Sep 22-28; 19(2): 33-9 (23 ref). 2004.
127