An Evaluation of the Expansion of Nurse Prescribing in Scotland

CHAPTER NINE : PUBLIC HEALTH AND PATIENT SAFETY IN NURSE PRESCRIBING

Introduction

9.1 This chapter assesses the extent to which public health and public safety are safeguarded in nurse prescribing with particular reference to microbial disease management. A full chapter has been devoted to coverage of this issue because it was a discrete objective of the project, and because nurse prescribing is considered to have definite public health benefits. Indeed nurse prescribing has the capacity for a potentially large impact on public health in almost every part of its practice. The impact may be direct or indirect or both. Hence there is a need, as the project objective identified, to look at the public health impacts of nurse prescribing in general and microbial disease management in particular.

9.2 The public health impacts of nurse prescribing will also be influenced by a number of factors including; good governance, the collection of reliable data on public heath benefits and risks of nurse prescribers. Tools are also needed for assessing and recording the effect of nurse prescribing interventions on microbial disease management, along with high quality prescribing education courses provided by higher education that address public health, continuing professional development and continued mentoring and support of nurse prescribers in practice.

9.3 This chapter presents its own literature review and draws on a range of data primarily from the survey of nurse prescribers, stakeholder interviews and case study sources (see chapters 3). Both broad public health and more narrow microbial safety topics are examined from the perspective of the nurse prescriber, the patient and other stakeholders.

Literature Review

Safeguards for public health and patient safety in nurse prescribing with particular reference to microbial safety

9.4 Relatively little research has been carried out on this subject. The major public health challenge of prescribing for microbial disease control in England has been explored by O'Brien (2005). The House of Lords, on one occasion, specifically debated nurse prescribing extensions in the context of the steps needed to 'guard against an increasing prevalence of antibiotic resistant organisms in the light of the Nurse Prescribing Regulations ( UK Parliament 2002 cited by O'Brien 2005). Other public health aspects of nurse prescribing have tended to be neglected.

9.5 The public health benefits from nurse prescribing in dealing with some fungal, bacterial and protozoal infections could be considerable with perhaps a lesser role in dealing with viral infections. No specific evidence exists about the benefits or costs of nurse prescribing activity with regard to reducing infections, illness times, hospital stays and treatment costs. Nurses have always played key roles in infection control and a further extension of their prescribing work and prescribing surveillance might well contribute more to controlling antimicrobial resistance. As 80% of antimicrobial prescribing occurs in primary care, the potential impact of nurse prescribers on appropriate prescribing and no prescribing at all for simple coughs and colds, viral sore throats and uncomplicated cystitis is considerable. Nurse prescribers may also have an important role in 'managing public expectations' of antimicrobial prescribing' and hence avoiding unnecessary prescriptions (O'Brien 2005).

9.6 There has been recognition that the process of assessing whether to prescribe or not may improve public health by non-prescribing of unnecessary antibiotics (Walsh 2006);

"Giving public health advice and support may be of greater value than prescribing. The patient may not require a prescription but may benefit from purchasing an over-the-counter product. Prescription costs may be prohibitive for some patients and giving them a less expensive option should always be considered" (Walsh 2006: S15).

9.7 Safe nurse prescribing will often operate in similar ways to safe medical prescribing. The role of education, training, supervision, mentoring will be central. In a clinical setting, it will also depend on proper clinical governance (Ryan 2004). Such safe prescribing should contribute to better public health. Nurses have already played a part in monitoring adverse drug reactions ( ADRs) since 2002 using the yellow card scheme (Baldridge 2005). Reducing ADRs will automatically improve the nation's health by cutting the admission of ADRs to hospital which currently account for 1 in 16 hospital admissions and 4% of bed occupancy (4%) (see also Harris et al 2004). Prescribing by nurses in family planning should produce a range of direct and indirect benefits for public health (Young 2006). Similar benefits may occur in the substance misuse field especially in primary care settings (Harniman 2006). In 2004, no studies were identified that had looked specifically at safety aspects of nurse prescribing but several studies in 2002 had shown patients and nurses were satisfied with the process and outcome of nurse prescribing (Harris et al 2004: 22-23). However, nurse prescribing education has been built into public health nursing training from 2006/7.

9.8 Ineffective prescribing wastes resources. Incorrect prescribing may threaten individual patient health. Such practices could have major ramifications and contribute either to a less rapid improvement in public health or possibly a decline in public health.

9.9 Data about the direct public health impacts of nurse prescribing are currently sparse and little is known about reckless or dangerous prescribing by nurses and midwives. What evidence does exist indicates that nurses are no more likely to prescribe dangerously than doctors and may prescribe more safely within tighter boundaries. There are several possible reasons why they may be much less likely to over prescribe, prescribe dangerously or inappropriately. These relate to such things as greater information available about past medical failures in over or wrongly prescribing antibiotics, and the greater caution of nurse prescribers who are especially concerned to work well within the limits of their knowledge and experience as our case study accounts recorded. A wide range of stakeholders indicated that they were aware of such matters (see below).

Microbial Disease Management

9.10 Nurse prescribers will impact upon microbial diseases in several ways. Inappropriate prescribing of antibiotics by the medical profession is now well recognised as a factor in contributing to antibiotic resistance of bacteria in the UK population. This recognition is therefore less likely to lead to over-prescribing by nurses who will be better informed about such problems (Price et al 2004).

9.11 The importance of antimicrobial resistance issues to nurse prescribing and public health has also been clearly recognised in recent years as has the problems of 'sub-optimal prescribing and poor adherence to prescribed regimes (McKinnon 2006). Nurses may sometime be best placed to spend more time with patients and hence could contribute to optimal prescribing and good adherence to prescribed regimes. Hospitals are responsible for prescribing only 10% of all anti-microbials but do so where there is a large and vulnerable patient population (McKinnon 2006).

9.12 The threats of microbial resistance to a range of control measures including therapeutic agents such as antibiotics has been recognised for over sixty years and has grow rapidly in the last 15 years. Some of the key and complex factors that singly or together may explain some of the major causes of such resistance have been described (McKinnon 2006). Until relatively recently, evidence about the effectiveness and cost effectiveness of 'strategies to contain the emergence of antimicrobial resistance' did not exist and the contribution that nurse prescribers could or did play was almost entirely neglected (Wilton et al 2002).

9.13 Several of our case studies indicate that nurses may be well placed or better placed than most health professional groups to address problems of sub-optimal prescribing and poor adherence to prescribing regimes. This relates to the greater time and, in some instances knowledge of patients that nurse prescribers may have. Nurses may also be best placed to reach vulnerable groups such as travellers, homeless people, asylum seekers and other transient populations because they were more accessible in clinics both in terms of numbers and location. Such groups often accessed clinics rather than GP surgeries.

9.14 GPs would often have to prescribe, in the field of tissue viability, without seeing the patient because they could not visualise the wound through bandages etc - and because they were prescribing on request of nurses who were undertaking the wound management (Walsh 2006). An example of how nurse prescribing could bring added benefits is outlined in the scenario below where nurses may take more time to explain possible side-effects of medicines as well as discussing appropriate administration of the medicine. It could well be that nurse prescribers in primary care may spend far more time prescribing and workloads may increase and nurse in secondary and tertiary care could benefit from such effective early interventions with lower case loads in their own sectors.

A patient scenario. A patient is visited at home by the local district nurse (DN) for management of a leg ulcer. The nurse assessed the ulcer and identified venous disease which requires compression therapy. As she cannot prescribe she asks the GP to write a prescription for dressings and bandages. The GP is not sure what these dressings and bandages are, but comply with the request as is usual practice. The DN takes the prescription to the pharmacist who dispenses 6 weeks worth of dressings and bandages. After 2 weeks the DN suspects that the patient is developing a wound infection. The DN takes a wound swab and returns to the GP and requests antibiotics for the patient. The GP visits the patient at home and agrees with the DN's diagnosis of an infected ulcer and prescribes antibiotics, however the infection has become worse. The DN thinks that the patient also requires topical therapy so returns to the GP once more for a prescription for antimicrobial silver dressings. Previous dressings lie unused in the patient's cupboard. Once the ulcer heals the DN measures the patient for compression hosiery and writes a note to the GP to prescribe hosiery. The GP writes a prescription for '2 pairs of compression stockings'. The DN then receives a call from the pharmacist asking for the size, class, length, type and colour of stockings that are required. Eventually the DN collects the prescriptions and fits the hosiery for the patient. Much time is spent as a messenger. As a nurse prescriber the DN would assess and manage the patient as before, but now does not need to return to the GP frequently for prescriptions for dressings or bandages. The DN also does not need to request large quantities at a time so can prescribe more cost-effectively. Once the possibility of infection becomes apparent, a topical antimicrobial dressing may be prescribed, without waiting for either swab results or a GP visit, for antibiotics. Therefore appropriate treatment may be achieved earlier on the care pathway, when required, possibly even preventing the need for systemic antibiotics. Once the ulcer heals the DN is able to measure, prescribe and fit compression hosiery to prevent recurrence of the ulcer.

9.15 Some GPs in rural areas were concerned about possible adverse effects of nurse prescribing;

"Maybe start to use an awful lot more and it cause all sorts of problems with MRSA and things like that. So I would think antibiotics should be restricted and maybe discussed with others around or bacteriologists or someone like that, there's a danger that might take off" (Rural GP)

Stakeholder perspectives

Ensuring patient safety as a contribution to public health

9.16 Stakeholders at the beginning of the project all re-iterated the belief that patient safety was paramount in the introduction and extension of nurse prescribing (Refer back to chapters where this is stated). How exactly this was to be operationalised and audited was not always clear. However, the greater the number of nurse prescribers there are prescribing safely in Scotland, the more patients and carers will be covered by their practice and hence there will be a community and public health impact as well as individual benefits.

9.17 For some stakeholders, ensuring patient safety of nurse prescribing related to careful selection of competent and experienced nurses who would then be trained in prescribing decision-making whilst for others it related to high quality courses to train prescribers. For yet others ensuring patient safety related to appropriate mentoring and support and advice of novice nurse prescribers working in a supportive 'team'.

9.18 Many viewed appropriate IT and electronic scripts as critical to patient safety to identify allergies, previous prescribing history and to prevent multiple prescribing that failed to take note of such matters as self-medication. Several stakeholders commented on studies from other countries showing nurse prescribers had lower rates of prescribing errors than medical colleagues but the literature review did not uncover these studies.

9.19 Some stakeholders flagged potential problems of de-regulated drugs which patients could receive over the counter but for which the nurse prescriber could not write a script. The need to evaluate the impact of de-regulated drugs was flagged as an important step to inform future nurse prescribing work.

9.20 Others recognised that new nurse prescribers who lacked experience might not identify signs and symptoms of serious illnesses which were similar to symptoms of common illnesses.

9.21 Stakeholders from patient groups perceived the complexity of the care process and the role that nurse prescribing played in that process. They recognised that a multitude of factors came into play affecting public health and patient safety. For example;

'We think nurse prescribing has the potential to increase accessibility and quality of care with the proviso of appropriate first class training and support, clear lines of clinical accountability and responsibility within health teams, clear lines of communication throughout the health service and equal access to high quality services for all people with (chronic disease condition) and we would want it to be evaluated by clinical outcomes rather than cost effectiveness' (Long-term conditions patient's group).

Case study findings

9.22 The case studies were specifically set up to explore several aspects of nurse prescribing practices and perceptions including views on public health. The public health and patient safety elements of the project research were explored through using the methods already outlined above: surveys, case studies, interviews and focus groups. This is because official statistical data availability are sparse or currently non-existent on these and related subjects. The objective, however, was researched by the various data collection methods used in the study and validated to some extent by cross referencing assessments by the prescribers themselves against that of non-nurse prescribers, doctors, pharmacists, health service managers and patients.

The nurse prescriber perspective

9.23 There is great potential for a range of 'nurse prescribing interventions' by nurses and midwives to impact on public health as data collected from the case studies demonstrates. Such interventions could relate to upstream health promotion, disease prevention and early diagnosis. The potential also applies to more downstream treatment, such as continued high quality care of long term or recurring conditions linked to such areas as tissue viability with non-pharmaceutical as well as pharmaceutical interventions playing a critical role.

9.24 In rural primary care and in a nurse-led specialist unit for instance, nurse prescribers identified public health benefits of nurse prescribing and showed they fully understood the considerable potential contribution that their work could make in this field;

"Public health, we're now involved in a lot of things that we weren't doing before, like smoking cessation clinics and things like that. We now take them; we share them with the health visitors, so we are doing a lot of prescribing there, a lot of nicotine replacement and stuff like that for them. And yes, I think that's somewhere where nursing is going to be expanding into public health because of the Cowie report and everything else, what they want is a sort of, you know proactive health service where you, its more to do with prevention than it is to sort of mopping up illness once it occurs and I think we are going to be involved in lots of other things there as well and it's a good chance for nursing to expand into these places, where they didn't before. ….The cumulative impact of clinical skills and knowledge is also important to the bigger public health picture as well as to individual patients and community health. (Rural nurse 2)

"I think if I was to show you the evaluation where we can see the impact that we've had on the improvement in the prescribing, in levels of prescribing, improvement in up-titration, improvement of use of medication and improvement of medication, the management of, of the medications that we're prescribing within the heart failure service, the benefits to public health are huge in the fact that we've reduced readmission and improved symptom control. We also, you know part of our role as well as nurses in the heart failure nurse liaison service is education, so you are continually trying to improve. So I would say you know the likes of where we are try, we try and have an impact on the patients to stop smoking for example, which is the part, a big part of the public health agenda". (Specialist unit nurse)

9.25 Another nurse prescriber in a rural setting did not at first recognise that her work was relevant to public health but went on to observe;

"Public health. No just really raising awareness as well you know what I mean. Like part of our role is for education as well for patients but I think we're at least giving them a bit of education about their tablets and what the effects are, whereas I think a lot of the time when they come into hospital they get started on tablets, nobody tells them what it is, why they are taking it or anything about that and I think you know at least that patient will ask question by then, now the majority of them know why they are taking these tablets whereas before I don't think they did. (Rural nurse prescriber)

"The fact that they're, you know, there's regular contact with them and what we're also trying to do by doing this and by prescribing them, getting them on optimum [medication] is ideally to try and keep them out of hospital and get on top of problems quickly" (Cardiac nurse practitioner).

9.26 This indicates that better and quicker treatment will reduce hospital admissions, increase care in the community setting and so contribute to the general public health of the country.

9.27 Mental health nurses did not perceive any public health benefits as particularly relevant to nurse prescribing in mental health. This does not correspond to the public's perceptions of major public health threats from mental health patients who fail to take prescribed products for a variety of reasons. There were some specific comments on aspects of patient safety and some nurse prescribers within mental health areas believed they had more specialised knowledge than non-prescribers and GPs. Hence nurse prescribing of medication would potentially be a) more accurate and b) the most appropriate type for patients with metal illnesses. Related to this was an observation about nurse prescribers having more time than GPs to discuss and decide on other forms of non-medication treatment, for example Cognitive Behavioural Therapy and anxiety management programmes. It was felt that nurse prescribers in mental health may be less likely to prescribe medication than a GP.

The GP Perspective

9.28 In a rural practice, one GP thought nurses needed more training on the safety aspects of prescribing to protect public health. Another observed;

"I would be worried if they had access to oodles of antibiotics. Because I think the danger that, I'm not being anti-nurse or anything like that but the danger that we could end up in trying to chase our tails on infections, specifically things like Fusidic acid which is an oral medication for Staph aureus and that's one we use very, very rarely and it was a danger that maybe, that would be an example some would……. And I would be worried if they had access to a lot of stronger pain killers because there's the risk of misuse and things like that, which we are probably better at policing. Its difficult for us to police that and I think it would be best if they kept out of that area, it would be another soft avenue for some patients to use and, so I think there's some areas that they should, they should not get involved in for the benefit of everyone else" (Rural GP).

9.29 The sound evidence base for such an opinion does not yet exist and, as the introductory section suggests, may relate more to a perceived threat to the medical role rather than the established limits of the nurse prescriber.

Hospital doctors' perspectives on the Public Health contribution of Nurse Prescribing

9.30 There was a wide range of medical opinions about nurse prescribers amongst hospital doctors. Some were very positive. One doctor, for example, had a very clear view of the public health benefits of nurse prescribing;

"Very positive about benefits in terms of morbidity and mortality. Through better patient care down the line in my view. Hence there will be public health benefits because of better care. Also the [doctor] noted that it would probably take pressure off GPs too. They do have an educational part to their role and I think it's more an individual benefit rather than a sort of community benefit. Its good for the individuals and their family and it keeps people out of hospital, it supports them at home and yeah I see these benefits from a greater public health, the remits not to educate or look at prevention, they do individual support but it's not [a] wider". (Consultant)

9.31 Others, probably partly dependent on their clinical location saw a narrower range of public health benefits. For instance, one junior doctor in an A&E setting saw value in nurse prescribers perhaps dealing with things like;

…tetanus immunisation, a couple of them in their nurse prescribing portfolios went and …looked in-depth at tetanus immunisation in the UK and that was quite interesting and I think…. from that point of view, ….. the thing that we use here and I'm sure it's in all of Scotland, the tetanus booster comes with Polio and Diphtheria. And I think its been good for the nurses because nurses give tetanus, you know the nurse prescribers sort of explain to the patients why, from a public health point of view, why they're having these extra 2 injections. .. I think educating people, you know, educating the patients about use of antibiotics, I think that's come into it as well. You know the nurse prescribers are very aware that we shouldn't be sort of giving everybody antibiotics for like wound, you know everybody for wound infection and stuff like that…… (Junior A and E Doctor)

Conclusion

9.32 Nowhere in the survey, case studies or stakeholder interviews were any nurse prescribing incidents or problems reported that affected patient safety. However, stakeholder groups, the health professionals themselves and their managers at national, board and local levels all identified the need for effective education, supervision and auditing of nurse prescribing work. For senior managers, this was viewed as an essential part of effective clinical governance. How extensive and exactly how effective such governance of nurse prescribers is may require further research. The capacity to demonstrate good governance at all levels and locations of nurse prescribing will provide important and necessary re-assurance for the prescribers themselves, the other health professionals they work with, the patients and public at large, user stakeholder groups and the Scottish Government.

9.33 The benefits to public health of nurse prescribing and its extension are potentially considerable and appear to be recognised by all parties.

Recommendations.

9.34 The contributions that nurse prescribers could make to public health were recognised by medical and nursing staff. The benefits to control of infections and the better treatment of conditions without the use of anti-microbial drugs or with more careful targeting of microbial drugs were also recognised albeit with some qualifications by some GPs. Nurse prescribers were generally believed to be competent and confident in relation to their prescribing areas. The public showed very considerable confidence in the nurse prescribing processes that they either experienced or hypothesised about. Such findings support the nation-wide omnibus study results.

9.35 Some nurse prescribers considered that elements of medical over-prescribing had been addressed by nurse prescribers who were more likely to know the appropriate amounts of products and medications within their competency areas. In addition, their training was said to have increased awareness about both budgetary constraints and holistic care. Hence some nurse prescribers believed they were less likely to prescribe unnecessary medication than GPs. Some GPs, however, expressed concern that nurse prescribers would not be as aware of the budgetary aspects of prescribing or the dangers of over-use of certain medications.

9.36 Nurse prescribers noted benefits in relation to patient safety because new prescribers were likely to be more cautious than those who have been prescribing longer. Patient safety and accountability for decision-making, well covered on the training courses, contributed to a cautious approach.

9.37 Public health benefits in relation to nurse prescribing emerged in areas where nurses had taken on further and more expanded roles, for example in smoking cessation and sexual health areas. Although public health benefits in primary care were widely recognised in primary care, they were also noted in relation to specialist nurse-led services with one recent audit showing reduced mortality, morbidity and re-admission rates linked to nurse prescribing.