Written by Padraig Denn, Introducing Nurse Prescribing to Private Cardiology Practice
I am going to investigate the processes involved in the development of a nurse prescriber role in a cardiology out-patient setting in a private facility in Munster. I will initially look at defining the nurse prescriber role in order to have a clear view of the role requirements. I will then look at the specific area for the new role and how the Irish Legal and Regulatory framework will impact on the role’s development. I will finally look at how accountability and ethical considerations will impact on the role and what skills and guidelines a nurse/midwife prescriber could use to ensure that the care they provide is not only effective but appropriate for each individual patient.
In order to investigate the development of nurse prescriber role in an outpatient setting we should first identify the definition of the role. I will review the development of nurse prescribing in Ireland later but in short nurse prescribing is built on both a legal framework and associated regulations and rules. The prescriber must be registered on the appropriate prescribers register and only prescribe medications that are commonly used in their specific area of expertise. Despite a thorough search of relevant literature, I was unable to identify a specific definition for the nurse prescriber role. Therefore, I propose the below definition of the role for the purposes of this article.
“Nurse/Midwife prescribing is a comprehensive process of amending an individual’s medical product regime by an appropriately educated and registered nurse/midwife prescriber within their scope of practice and area of expertise. This process encompasses effective assessment of the individual and their problem whilst adhering to local and national laws/regulations/policies/guidelines as part of a patient centred care approach. The resultant prescription should adhere to best practice documentation guidelines and should be subject to comprehensive auditing to ensure consistency and accuracy.”
The National Nursing and Midwifery board (NMBI) (registration authority in Ireland for Nurse Prescribers) and the Health Services Executive have laid out the rules and regulations for the nurse/midwife prescribing role in numerous publications. I will explore these in more detail later.
I am currently the manager of an outpatient cardiology department which includes a nurse lead Acute Cardiology assessment unit, heart failure clinic, cardiac rehabilitation nurse led service and we are in the process of developing a cardiology nurse research post. It is planned to expand my current role to encompass the assessment and management of non-acute cardiology presentations, in conjunction with the lead cardiologist, to improve the throughput in out-patient clinics. A significant component of this role would be the active management of patient’s conditions which would involve effective prescribing of medicinal products.
The out-patient services are based in a private healthcare facility in the Munster region and will be the first private clinic in Munster to have an Advanced Nurse Practitioner (ANP) role as part of the day-to-day management of the broad spectrum of non-urgent out-patients.
In this article I will look at the important components of effectively integrating this new advanced nurse role into a preexisting clinical setting whilst ensuring that national legal and registration guidelines are adhered too. I will also consider the personal considerations of taking on this new role in the above setting.
Scope of Nursing for Prescribing
The implementation process for nurse prescribing in Ireland had its infancy in two reports that were published in the late 1990’s early 2000. The commission of Nursing (Government of Ireland, 1998) and the Review of scope of Practice for Nursing and Midwifery (Final Report) (An Bord Altranais, 2000).
Based on the recommendations of theses report a review was commissioned in 2001 into the possibility of extending the role of nursing to include prescribing. The review was carried by a team from An Bord Altranais and the National Council for the Professional development of Nursing and Midwifery. There review was published after three and a half years of assessment in 2005. This review recommended that prescriptive authority should be extended to nurses and midwives (Drennan et al., 2009).
The then Minister for Health and Children, Mary Harney, brought the recommendations of the report to cabinet. The Minister’s rationale for the extension of prescriptive authority to nurses and midwives was to improve services to patients, reduce health service delays and deploy the education and expertise of nurses and midwives more efficiently (Creedon and O’Connell, 2009).
Once it was cleared by Government in 2006 it was signed into law in several legal acts in 2006 and 2007.
- The Irish Medicines Board (Miscellaneous Provisions) Act 2006 (Commencement) Order 2007.
- The Medicinal Products (Prescription and Control of supply) (Amendment) Regulations 2007.
- The Misuse of Drugs (Amendment) Regulations 2007.
Over the subsequent years the specifics of requirements for effective and safe nurse prescribing have been reviewed and amended accordingly. Initially the guidelines from An Bord Altranais (now called Nursing and Midwifery Board of Ireland, NMBI) and the Health Services Executive (HSE) identified that to ensure safe prescribing practices it needed to be identified by the individual prescriber and their clinical mentor which specific medications the prescriber would be allowed to prescribe, this was called the Collaborative Practice Agreement (CPA) and was a requirement for registration with the NMBI. This however is no longer a requirement in Ireland as it was found to be too restrictive for the prescriber particularly when you look at the frequency and number of changes that occur in medications over the years. Therefore, in 2018 this requirement for registration as a nurse/midwife prescriber was discarded. It was replaced with a recommendation that the prescriber’s area of clinical practice implement local policies and guidelines about the prescriptive authority of each individual prescriber. Along with this change over the intervening years the restriction of Nurse/Midwife prescribers prescribing Controlled and Non-licensed medications has also been amended to allow for a more comprehensive list of medications available for everyone to add to their agreed list of medicinal products (ONMSD and HSE, 2020). These changes have been reflected in associated amendments to the legal framework supporting the prescriptive authority of nurses/midwives.
- Nurses and Midwives Act 2011 (S.I. No 41 of 2011)
- Misuse of Drugs Regulations 2017 (S.I No. 173 of 2017).
- Nurses and Midwives Rules 2018 (S.I. No. 219/2018-Register of Nurses and Midwives, S.I. No 218/2018-Education and Training).
- Medicinal Products Control of Placing on the Market) Regulations 2018 (S.I. No. 529 of 2018).
With the regular amendments to the legal framework supporting the implementation and regulation of nurse/midwife prescribing there has been concurrent development and amendments to the clinical guidelines and practices overseeing the prescriptive authority of the nurse/midwife prescriber. The Office of Nursing and Midwifery Services Director and the Health Services Executive have identified the below as the core guidelines for nurse/midwife prescribing: (ONMSD and HSE, 2020)
- Recording Clinical Practice Guidance to Nurses and Midwives (An Bord Altranais, (2002)
- Guidance to Nurses and Midwives on Medication Management (An Bord Altranais, (2007).
- Requirements and Standards for Education Programmes for Nurses and Midwives with Prescriptive Authority (An Bord Altranais, 2007).
- Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives (NMBI, 2014)
- Scope of Nursing and Midwifery Practice Framework (NMBI, 2015)
- Practice Standards for Midwives (NMBI, 2015)
- Practice Standards and Guidelines for Nurses and Midwives with Prescriptive Authority, 4rd edn (NMBI, 2019)
According to the NMBI (2015) the scope of nursing practice is the range of roles, functions, responsibilities and activities which a registered nurse is educated, competent and has authority to perform. Therefore, with the removal of the requirement for a CPA for nurse/midwife prescribing the specifics of what an individual prescriber has the competency and authority to prescribe falls to the employer. This can be supported through addition or amendment of local clinical policies and guidelines. Having these guidelines developed in collaboration with all relevant members of a multidisciplinary team will allow for easier implementation of practices that reflect the specific clinical setting rather than depending on generic national or international policies which would be difficult to implement in very specific clinic settings.
Implementation into Private Cardiology Out-Patient Clinic
As mentioned above I am working in a cardiology out-patient service in a private healthcare setting in the Munster region. There is a development plan in place to improve patient throughput by implementing an advanced nurse practitioner role in the coming months. In order to ensure that this role is implemented in an efficient and effective manner it is imperative that all aspects for the role and how it fits into existing structures are examined.
International research has identified a wide variety of benefits to the implementation of the nurse prescriber role into the clinical setting with some reporting that it is the single greatest development in the nursing since it became a profession (Dowden, 2016). Numerous authors have identified efficiency and patient benefits to the development of the nurse/ midwife prescriber role. These benefits vary from improved patient satisfaction, improved waiting times, maximising resources and improving patient access (Courtenay et al., 2010; Carey and Steiner, 2011; Ferro, 2011; Griffith, 2013 and Milligan, 2012) to improvements in prescribers self-perception of the effectiveness of their patient care journey along with extension of their knowledge base for both medicinal products and the legal/ administrative requirements that are associated with it. The research has shown that nurse/ midwives are as effective as their medical colleagues at prescribing effectively and appropriately and identifying/reporting adverse medication events (Morrison-Griffiths et al., 2003 and Black & Dawood, 2014).
However, despite the above dearth of research about the benefits of nurse/midwife prescribing in the effectiveness of the care they provide when compared with our medical colleagues some issues have been identified with implementing the practice. Bradley et al. (2007) identified that despite undertaking an appropriate educational programme and registering as a non-medical prescriber 26% (n=8) of their respondents had not yet prescribed any medicinal products. Although this research is based on a small cohort the findings are significant. The authors elaborated on their qualitative research finding and identified several areas that the respondents believed limited their ability to prescribe once qualified. They noted that the perception of patient safety was a key factor. The respondents also noted that although having completed the pre-requisite educational component for registration they felt this was only a starting point in their theory training, this perception is supported research conducted by Boreham et al. (2014) in their review of nurse prescriber training in Scotland.
Bradley et al. (2007) identified that a key component to effective nurse/midwife prescribing was the integration with the practice within existing clinical structures and the support of members of the multi-disciplinary team with the development of the role and their support in ongoing educational needs of the role. The absence of this component of nurse/ midwife prescriber training has been identified by Casey et al. (2019) as a key barrier to effective implementation of the nurse/ midwife prescriber role.
There are national guidelines, produced by the NMBI to assist nurse/midwife prescribers in their day-to-day patient centred care processes. One central component for the safe and effective prescribing of medicinal products is the code of professional conduct and the associated five principles (See Appendix 1). Two further key components of effective prescribing were identified by the NMBI in the 4th edition of Guidelines for nurses and midwives with prescriptive authority (2019). These included the eleven practice standards for nurse/midwife prescribing (See Appendix 2) and a decisionmaking framework (See Appendix 3). These were seen as the key factors required for the effective implementation of Nurse/Midwife prescribing when first commenced in Ireland (HSE, 2007).
As mentioned earlier with the withdrawal of the need to have a CPA in practice there is a requirement to have an established framework in place in the prescriber’s area of clinical practice to not only support them in their practices but also to ensure that any practices are evaluated and amended as required to ensure the practitioner is working within their scope of practice and are treating their patients with the most up to date interventions. This issue was identified above when the barriers to effective implementation of the nurse/midwife prescriber role were highlighted. In my area, as it is a new venture for the hospital a comprehensive review of current policies and practices was undertaken to identify what components needed to be amended. This process was overseen by my clinical mentor, the hospitals nurse prescribing supervisor and the hospitals Drugs and Therapeutics committee. A possible benefit of this collaborative approach would be to ensure that all key stakeholders in the process have an input in the process and thus be more likely to support the prescriber in the day-to-day activities and their ongoing professional development, thus avoiding the potential barriers identified above regarding effective implementation of the role.
Accountability of Nurse Prescriber Role in Out-Patient Cardiology setting
As mentioned earlier nurse-led clinic allow for timely treatments by nurse/midwife prescribers.
These clinics allow specialist nurses to develop advanced skills and manage specific caseloads with relative autonomy. With this autonomy comes increased risk and accountability is essential to the protection of patients receiving care in nurse-led clinic (Griffiths, 2013). According to the ONMSD and HSE (2020) practicing in an accountable manner requires a sound knowledge base in order to ensure that the nurse/ midwife prescriber can justify their course of treatment or omission of treatment. In Ireland the code of conduct for nurses and midwives has as one of its five core principles professional accountability of actions and omissions in care (NMBI, 2021).
In Ireland the requirements for acceptance into the theoretical component of nurse/midwife prescriber training states that the participant needs to already have extensive experience in the specific area of practice (Lotto, 2018). The courses although generic in their application of theory expect the individual participant to apply the new knowledge to their area of practice. There is also a component of evaluation of course completion through a logbook of the implementation of the theory into clinic practice. This multifaceted approach to education of the nurse prescriber is designed to meet the standards set out by the ONMSD and HSE for effective theoretical training of nurse prescribers to ensure a sound knowledge base and associated accountability of decisions made in practice. However, applying theory to practice may not be so straight forward.
In 2006 in the United Kingdom Jan Keenan, a leading cardiac nurse consultant, identified that the restrictive nature of specific formulary-based nurse prescribing was leading to impaired care delivery in nurse-led clinics (Keenan, 2006). This issue was formally recognised in Ireland with the removal of the CPA in 2018.
However, one must recognise that the presence of the CPA was a crutch to assist the newly qualified prescriber in their dayto-day decision-making process by providing a clear structure to their prescribing options. The removal of the CPA potentially limits the newly qualified prescriber to implement a treatment plan. Casey et al. (2019) reported in their qualitative study that nurse prescribers reported low levels of confidence in their abilities to alter medications already prescribed by another member of the multidisciplinary team. The HSE and ONMSD also recognised the issue of removal of the CPA in their 2020 National Nurse/Midwife prescriber guidelines by recommending the utilisation of national prescribing guidelines and amending them to fit local practices to support front line nurse/midwife prescribers (ONMSD and HSE, 2020).
However, the newly qualified nurse/midwife prescriber must remember that available research has shown that nurse prescribing is as effective/appropriate as our medical colleagues, medications errors are often reduced, and nurse/midwife prescriptions are compliant with pre-established documentation guidelines (Carey and Steiner, 2011). As mentioned earlier the utilisation of a multidisciplinary approach to the development of a new nurse/ midwife prescribing service is essential to ensure appropriate structures are in place for safe practice. It should also be noted that this structure can also aide the prescriber in their decision-making processes (Bradley and Riley, 2013).
In practice the utilisation of a decision-making framework has also been shown to aide the process of effectively prescribing and this allows the prescriber to be more accountable for their decisions as they can reference this framework if any adverse events occur. Moore (2019) described the utilisation of such a framework in prescribing home oxygen for patients with chronic obstructive pulmonary disease who continued to smoke. The NMBI also have a decisionmaking framework in their Practice Standards for Nurses and Midwives with prescriptive authority, see appendix 3 (NMBI, 2019).
Therefore, in order to support a nurse/midwife prescriber in the management of a case load of patients a facility should ensure that there are appropriate local guidelines that would include a decision-making framework. There should also be appropriate support from members of the multidisciplinary team to ensure that the prescriber feels they can ask questions about their prescriptive decisions. The knowledge base, decision making framework, appropriate local policies and the support of colleagues will ensure that the nurse prescriber is accountable for their decisions and ensure the patients receives the most appropriate and effective level of care.
Ethical Considerations of Prescribing in a Cardiology Setting
As mentioned above the work highlighted by Moore (2019) prescribing Oxygen therapy to a patient who continues to smoke brings with it some issues around safety for the patient. Taking this one step further should we consider the ethical component of such a decision, is it in the patients’ best interests to commence oxygen therapy?
This can also ring through when we look at prescribing medicinal products for cardiac patients. In general, Cardiac patients will have concurrent co-morbidities due to the general cohort of patients being older and with increased age comes worsening health issues. A prescriber needs to assess if the decision-making framework, local guidelines and national/ international recommended treatment for a specific problem is in the patient’s best interests?
As an example, a 65-yearold gentleman who is on pharmaceutical treatment for benign prostatic hypertrophy and presents to a cardiology clinic for newly diagnosed hypertension. He is frail and has been prone to dizzy spells and recently fell and cut his head due to this dizziness. The guidelines would suggest that he is immediately commenced on antihypertensive therapy and ideally a dual medication approach (Williams et al., 2018). However, when we assess the patient, we see significant concerns about his wellbeing with the initiation of treatment as per guidelines. The effect of the newly commenced antihypertensives could be potentiated by the existing α-blocker treatment for his prostate issue and worsen his dizzy spells and result in an increased numbers of falls. This would result in a worsening quality of life as he would be restricted in his daily activities. Therefore, would it be ethically correct to improve this gentleman’s blood pressure readings whilst worsening his quality of life.
It must be remembered that any decision in healthcare will have an impact on another individual and usually that individual is the patient. Therefore, when we look at prescribing in any setting, we must first consider the patient, their needs, expectations and beliefs. O’Connor and O’Dea (2021) present a comprehensive introduction to the issue of Human Factors in the decision-making process. Although the patient is not the only Human factor to consider as per the diagram representing human factors (See Appendix 4) they are central to the process of decision making in healthcare.
Therefore, for any ethical discussion to happen the first step is to involve the patient in the process. Allow them to be central to the decision-making process by educating them about the risks and benefits of any potential treatment regime and allowing them the space to decide if the treatment is in their best interests.
Although the role of nurse prescriber has been present in the Irish healthcare system as an entity for nearly twenty years it is an ever evolving practice. The role itself has been poorly defined and varies from setting to setting and even within individual healthcare settings. The benefits of the nurse prescriber role have been clearly described in various publications but the success of implementation has been reported to be varied and occasionally stagnated. It has been clearly identified that to effectively implement a new prescribing process in a clinical setting requires effective support and defined frameworks to assist the new prescriber in the development of the skills and knowledge to safely treat a specific patient cohort. This framework and support structure needs to be developed through effective collaboration with various members of the multidisciplinary team. The aim of the process being to ensure that the new prescriber can safely, autonomously and ethically decide on the most appropriate medicinal regime for every individual within their defined patient cohort.
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