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