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Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 Title : Standing Orders In New Zealand Primary Care. Research Portfolio. 1 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. 2 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. 3 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. 4 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. 5 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. 6 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] 7 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 8 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 9 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) 10 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. 11 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. 12 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 13 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 14 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 15 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. 16 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 17 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]. 18 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 19 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 20 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 21 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. 22 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 23 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 24 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 25 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 26 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 27 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 29 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 30 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 31 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 32 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 33 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 34 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 35 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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? 36 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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: 37 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 38 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 39 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 40 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 41 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 42 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 43 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 44 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 45 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 46 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 47 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 48 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 49 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 50 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 51 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 52 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 53 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 54 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 55 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 56 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 57 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 58 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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] 59 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 60 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 61 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 62 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 63 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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) 64 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 65 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 66 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 67 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 68 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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) 69 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 “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 70 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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: 71 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 “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) 72 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 “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%) 73 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 (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%) 74 12 (80%) Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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) 75 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 76 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 “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 77 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 78 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 79 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 80 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 81 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 82 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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. 84 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 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 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 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 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 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 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 Joseph Scott-Jones Paper - MMSc Research Portfolio Student Number 2323583 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 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 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. 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