What is the contribution of nurse prescribers to medicines optimisation? Current practice and challenges ahead Prof Sue Latter, Health Sciences, University of Southampton

Nurses and medicines optimisation 675,000 nurses registered in the UK Working in a variety of settings; homes and schools, workplaces, A and E, hospital wards, nurse-led clinics, outreach teams, community and primary care, nursing and care homes Contribution to medicines optimisation through: preparing, supplying, administering and prescribing medicines, monitoring and review, patient education, multi- disciplinary liaison and care interface communication

Nurse prescribers and medicines optimisation 54,000 nurse prescribers in the UK Over 20,000 independent nurse prescribers, prescribing across whole formulary Preparation: 3 years post qualification; 26 days in HEI taught course + 12 days with Designated Medical Practitioner Radical model, comparative to other countries Experience, extra training, greater autonomy

Setting% NIPsMean hrs/wk % PIPsMean hrs/wk GP practice40.8% %5.1 NHS hospital Trust28%33.935%4 Home visits20.9% %1.3 Walk-in Centre6.7% %2.0 Family planning clinic 4.8%8.2-- Care homes3.6%6.41.4%1.0 Nursing homes3.5%5.50.7%2.0 Sexual health clinic2.4% %8.5 NHS Mental health Trust 1.0% %2.7

Scale of NIP and PIP Hospital / Foundation Trusts: Mean number of: NIPs per Trust 21.4 PIPs per Trust 2.0 Primary Care Trusts: Mean number of: NIPs per Trust 74.9 PIPs per Trust 1.9

Treatment areas prescribed in most frequently NIPs%PIPs% Infections15.3%Hypertension25.0% Asthma9.8%Cardiology9.6% Diabetes7.9%Asthma6.6% COPD6.1%CHD prevention5.8% Family planning5.8%Care of older people 5.8% Wound care5.6%Oncology5.8% Dermatology4.2%Diabetes4.4% Pain management 4.0%Infections4.4% Minor injuries3.9%Drug/subs. misuse3.7% Cardiology3.7%Gastrointestinal2.9%

Scope and scale of NMP 66.4% of NIPs and 42.7% of PIPs report prescribing instead of a doctor in their main treatment area The average consultation time reported by NIPs for a prescribing consultation was minutes and for PIPs minutes.

MAI question NIP % appropriate PIP % appropriate Is there an indication for the medication?93%96% Is the medication effective for the condition? 97%98% Is the dosage correct?91% Are the directions correct?88%90% Are the directions practical?97%98% Are there clinically significant medication / medication interactions? 97%95% Are there clinically significant medication / condition interactions? 94%91% Is there any unnecessary duplication with other medications? 98% Is the duration of therapy acceptable?95%98% Is the drug the least expensive alternative..? 88%79%

Ireland: national evaluation 142 patients, 208 medicines prescribed by 25 nurses 95-96% of medicines prescribed were indicated and effective for the diagnosed condition Criteria relating to dosage, directions, drug-drugs or disease condition interaction, and duplication of therapy were judged appropriate in % of prescriptions Duration of therapy received the lowest value at 76%. Overall, reviewers indicated that between % of prescribing decisions met all eight criteria. Naughton et al (2012)

A & E and sexual health prescribing 764 case notes from NIPs in 1 London A & E Over 53.5% (n = 409) of prescribers’ patients required medication Analgesia was most commonly prescribed in accident and emergency (31%, n = 85) Antibiotics in sexual health (55%, n = 162) Safe prescribing practice was evident in 99.4% Black (2012)

Patients’ experiences and preferences Acceptability of IP to patients is high, as evidenced by the majority of patients reporting that they were ‘very satisfied’ with their visit to the nurse (94%) or pharmacist (87%) prescriber Tinelli et al (2013)

Patients’ experience & preferences Discrete Choice Experiment findings also showed that patients valued pharmacist and nurse prescribing services as an alternative to GP prescribing in primary care. Preference for own doctor, but certain attributes of the consultation - listening to patient’s views about medicines; explanation about medicines, were valued more than the profession of the prescriber. Gerard et al (2014)

Challenges Promoting adherence Prescribing for co-morbidities & complexity Acute sector prescribing / antimicrobial stewardship

UK guidance on adherence RPS (2013) understand patient experience NICE (2009) guidance: –address perceptions and practicalities –Necessity-Concerns Framework (Horne and Weinmann 1999) –‘be aware that patients’ concerns about medicines, and whether they believe they need them, affect how and whether they take their prescribed medicines

Are nurses’ promoting adherence? Little research on nurses (Stevenson et al 2004) Latter et al NAME papers Evidence on UK nurse prescribers suggests opportunity is not being fully exploited Sibley et al 2011: 20 NIPs; 59 consultations; 260 medicine discussions most frequently raised themes were: ‘medication named’ (88.8%) ‘usage of medication’ (65.4%) ‘instructions for taking medication’ (48.5%) ‘reasons for medication’ (8.5%) ‘concerns about medication’ (2.7%). ‘Instructional’ communication most prevalent Professional development is required to support evidence-based approaches to medicines optimisation 15

Prescribing for co-morbidities 58% of NIPs agreed / strongly agreed that they have concerns prescribing for patients with co-morbidities 28.5% of PIPs agreed or strongly agreed with this statement. Latter et al (2011)

Prescribing for co-morbidities & complexity Greater proportion of community matrons reported less access to support & supervision to underpin their prescribing (Smith et al 2014) Herklots (2013) –prescribing-related knowledge essential –the ability to prescribe speeds patient access to medicines and may be instrumental in preventing hospital admission –prescribe a limited range of medicines regularly, whilst referring to GPs for other prescribing outside their competence –Mostly access their support from GPs and consider this adequate in supporting them in their prescribing role.

Prescribing for co-morbidities & complexity CMs prescribing a similar range of meds – COPD exacerbations and infections variation in confidence in prescribing for conditions beyond this core group of drugs: I’m happy with exacerbations and chest infections… UTIs and wound infections, but anything that’s going beyond that I just don’t feel confident in myself to be going out and doing that, I really feel that to me is a doctor’s job (CM7)

You see I don’t think I have increased my scope over the years to be frank, I think I have quite a limited range that I feel confident doing, using and I haven’t gone outside it…I think the knowledge and skills are there to impart information and support to the patients.. but I certainly don’t feel the need to suddenly become an expert in you know, Parkinsons meds or anything, I just wouldn’t touch it (CM1)

Prescribing for co-morbidities & complexity Enhanced training for prescribing? Working with pharmacists RPS Commission on future models of pharmacy: examples of multi-disciplinary working to support complex meds management

Prescribing for co-morbidities outreach pharmacists employed by hospitals or community services, forming part of the care team for frail older people in particular E.g. Guy’s and St Thomas’ Community Services team have pharmacists as core members, working with nurses and others to manage complex patients in the community to avoid unnecessary admissions or re- admissions.

Acute sector prescribing Main setting reported by 28% of NIPs in 2011 national survey Little robust evidence on current practices and contribution to key issues: –Communication between care settings –Integrated primary and secondary care systems –Antimicrobial stewardship

Acute sector prescribing Kroezen (2014) hospital nurse specialists –Great variety in prescribing – frequency and type –Extensive number of protocols, guidelines and formularies –Highly frequent, informal consultation between nurse and medical specialists about nurse prescribing –Difficulties: new professional power relations; lack of organisational readiness Local flexibility or lack of strategic thinking?

Acute sector prescribing Need for UK data on what areas, what medicines and how the role is being utilised to achieve key policy objectives e.g. antimicrobial stewardship

RCN (2014) Reduce demand for antibiotics Enhance effectiveness of prescribed antibiotics –Awareness of, and ensuring compliance with, policies –Ensuring clear and accurate prescription processes –Dispensing at the right time and correct circumstances –Educating patients and carers re self-administration

Nurse role in AMS Sustained, seamless level of monitoring and decision- making (Edwards et al 2011) Questioning and highlighting suboptimal drug therapy Appropriate therapy is promptly initiated Check for allergy status Ensure potential for switching from intravenous to oral therapy is reviewed (Ladenheim et al 2013)

Nurse role in AMS But still we know very little about nurses and / or nurse prescribers’ current practice and roles in AMS Role of acute care nurse and development of intervention Quality and safety and influences on practice nurses’ AB prescribing Intervention for hospital-based prescribers to improve initial AM prescribing

Conclusions Large workforce, practising in variety of settings Expanding number of nurse prescribers with autonomy and capacity to independently manage patient episodes of care Prescribing safely within defined areas But –must use evidence-based consultations to promote adherence –engage with others on complex prescribing for enhanced patient experience –use prescribing authority proactively and strategically in all settings

Necessity Concerns Framework Higher adherence was associated with stronger perceptions of Necessity of treatment (p ) and Fewer Concerns about treatment (p ) These relationships remained significant when data were stratified by study size, country and type of adherence measure used Taking account of patients’ necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions Horne et al(2014)

‘Adherence’ or medicines optimisation Medicines self-monitoring and self-management appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes (Ryan et al 2014) ‘Some evidence’ for: –education + skills training, counselling, support, or enhanced follow-up; information and counselling delivered together –practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives

RCN (2014) Electronic systems for prescribing, dispensing and administering, for accurate data Simplified language – ‘prescribers’ so best practice messages are seen as relevant to all Strengthening nurse education on pharmacology associated with antimicrobial prescribing and AMR