A Review into the Impact and Status. Nurse Prescribing. Northern Ireland (Final)

A Review into the Impact and Status of Nurse Prescribing in Northern Ireland 2014 (Final)

Published by The Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) April 2014 Acknowledgements NIPEC is grateful for the large volume of engagement with patients and professionals during this review. NIPEC also wishes to extend thanks to the Steering Group who overseen the process of the review. This review has been dedicated to the memory of one of the Steering Group members Valerie Hall, who sadly passed away before the final report was completed. Permission to make photocopies of identified parts of this document for personal use is granted without fee, provided that copies are not made or distributed for profit or commercial advantage. To copy otherwise, to republish, to post on servers or to redistribute to lists requires prior specific permission from NIPEC. Copyright Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC)

CONTENTS PAGE 1.0 INTRODUCTION 1 2.0 METHODOLOGY 2 3.0 OBJECTIVES 2 4.0 BACKGROUND 3 5.0 NURSE PRESCRIBING EDUCATION PROGRAMMES 5 6.0 REGISTRANTS IN NORTHERN IRELAND 7 7.0 ENGAGING WITH PROFESSIONALS 8 8.0 ENGAGING WITH PATIENTS/CLIENTS 9 9.0 FINDINGS 10 10.0 EDUCATION 10 11.0 PRACTICE 16 12.0 SUPPORT AND PROFESSIONAL DEVELOPMENT 23 13.0 PATIENTS'/SERVICE USERS' EXPERIENCE AND IMPACT ON PATIENTS OF NURSE PRESCRIBERS 32 14.0 MAPPING TO NIPEC (2007) RECOMMENDATIONS 37 15.0 ENGAGEMENT WITH NURSING AND MIDWIFERY COUNCIL 37 16.0 CONCLUSIONS AND RECOMMENDATIONS 38 APPENDICES APPENDIX ONE Membership of the Steering Group 40 APPENDIX TWO NIPEC Review of the Implementation of the Nurse Prescribing Role (June 2007) 41 APPENDIX THREE Nurse Prescribing Individual Questionnaire 2013 42 APPENDIX FOUR Nurse Prescribing Health and Social Care Organisation Questionnaire 2013 47 APPENDIX FIVE NIPEC Flyer Nurse Prescribing in Northern Ireland 50 APPENDIX SIX Health and Social Care Trusts - Service User / Carer/ Family Engagement Questionnaire 51

1.0 INTRODUCTION 1.1 This project aimed to review and assess the current status and impact of nurse prescribing in Northern Ireland (NI). It was commissioned by the Chief Nursing Officer (CNO), Department Health Social Services and Public Safety (DHSSPS). 1.2 Nurse prescribing in NI, was implemented through a phased roll-out from 1999 for District Nurses (DN) and Health Visitors (HV). The aim was to achieve full implementation by December 2001, following the publication of guidance from the DHSSPS (2000) 1. 1.3 In addition, a nurse prescribing module was incorporated into the DNs and HVs training programme. These nurse prescribers are known as Community Practitioner Nurse Prescribers (CPNPs). The first cohort of Nurse Independent/Supplementary Prescribers (NISPs) completed their training in 2004, this group of nurse/midwife prescribers were initially able to prescribe from a limited formulary. These formulary restrictions for NISPs have now been removed and as a result a NISP may prescribe from the full British National Formulary (BNF), 2 within his/her area of competence. Both of the CPNP and NISP programmes meet the requirements of the regulatory body, the Nursing and Midwifery Council (NMC). 1.4 A UK study (2011), Nurse prescribing roles in acute care: an evaluative case study 3, expressed the view that, 'In the light of growing evidence of the competency of nurse prescribers, it is now timely to focus less on behavioural and affective measures of prescribing performance and more on the impact that the role may have on enhancing the quality and safety of patient care, such as identifying those interventions that improve patient safety by reducing prescribing errors'. 1.5 Although a number of developments in nurse prescribing have taken place in NI, evaluation of the impact of prescribing on patient care has not been undertaken. A recent NI review with Mental Health Nurse Prescribers (PHA 2012, unpublished) identified a number of issues which have negatively impacted on the implementation of prescribing within this field of nursing practice. 1.6 Northern Ireland Practice and Education Council (NIPEC) agreed to lead and deliver on the project, with an aim to: 'describe the current position and assess the impact on patients/clients of nurse prescribing within the delivery of health care services in Northern Ireland'. 1 Department Health Social Services Public Safety (2000) Nurse prescribing - Guidance for Implementation Feb 2000 Belfast, DHSSPS (revised Oct 2000) 2 British National Formulary 66 Sept 2013-March 2014 3 Jones K., Edwards M. & While A. (2011) Nurse prescribing roles in acute care: an evaluative case study. Journal of Advanced Nursing 67(1), 117 126. doi: 10.1111/j.1365-2648.2010.05490.x 1

2.0 METHODOLOGY 2.1 To achieve the overall aim of the project, a Steering Group was established, comprising representation from the Public Health Agency (PHA), all of the five Health and Social Care (HSC) Trusts, and the Education Providers (Appendix One). 2.2 A project plan, including a set of objectives, terms of reference and a work programme was developed and agreed with the Steering Group which was chaired by Oriel Brown (PHA) with Brenda Devine (NIPEC) as project lead. 2.3 Initially it was agreed to conduct the project over a nine-month period which commenced in April 2013. However, due to reasons which are described later in this document this timescale was extended. 2.4 Having agreed on the project initiation document (PID), the Steering Group decided on the various methods of engagement with nurse prescribers, HSC employers, patients and clients. These engagement processes aimed to inform the project team of the current status of nurse prescribing, and to describe the impact on patients and carers. 3.0 OBJECTIVES 3.1 The following objectives were agreed: i. Identify the number of places commissioned for the NISPs programme and associated attrition rate (from 2003). ii. Determine as far as might be possible the number of staff trained (NISP and CPNPs) in each area of prescribing. iii. Identify the number of staff who are 'actively' prescribing within their role. iv. Determine the number of items prescribed annually. v. Highlight exemplars of good practice, seeking to identify any relevant evidence of added value in terms of patient/client safety, outcomes and of improvements within the Health and Social Care. vi. Ascertain the status of organisational structure, commitment and support to nurses who are prescribing within Northern Ireland. vii. Identify barriers to prescribing, and who should be responsible for specific recommendations. viii. Present findings, draw conclusions and make recommendations and prepare a report of the work. ix. Submit a final report to the Department Health Social Services and Public Safety through the office of the Chief Nursing Officer (CNO). 2

3.2 There are a number of different nurse prescribing programmes which are referred to in the body of this report. For ease of reference, the programme code and qualification have been listed in Table 1 below: TABLE 1 - NURSE PRESCRIBING CODE AND QUALIFICATION Code Qualification V100: Community Practitioner Nurse Prescriber V150: Community Practitioner Nurse Prescriber (without Special Practice Qualification or Specialist Community Public Health Nurse) V300: Nurse Independent / Supplementary Prescriber 4.0 BACKGROUND 4.1 Community Practitioner Nurse Prescribers (CPNPs) As noted earlier, a nurse prescribing module (V100) has been incorporated into the training programmes for DNs' and HVs' since 2001. From 2013, there is now the opportunity for staff nurses who work in the community in NI to complete a nurse prescribing programme (V150). CPNPs, prescribe from a limited British National Formulary (BNF) 4. The BNF provides up-to-date, practical guidance on prescribing, dispensing, and administering medicines. This guidance is reviewed and updated every six months. 4.2 Nurse Independent Supplementary Prescribers (NISPs) In 2003, NI embraced new developments in nurse prescribing by implementing the Extended Independent Supplementary Nurse Prescribing programme. This programme was approved by the Nursing and Midwifery Council (NMC) and was subsequently renamed Nurse Independent and Supplementary Prescribers (NISPs- V300). The first cohort of registrants who successfully completed this programme was able to prescribe from 2004, following the completion of the programme. (It is relevant to note that the first NISP programme was of a six month duration but from October 2003 it was extended to a full academic year-long programme). 4.3 In 2006, the NMC developed the Standards of Proficiency for Nurse and Midwife Prescribers (NMC, 2006) 5. These provide a professional framework for practitioners and a guidance document for Higher Education Institutions (HEIs) and includes the 4 British National Formulary 66 Sept 2013-March 2014 - Page 1046 Formulary for CPNPs 5 Nursing and Midwifery Council (2006). Standards of proficiency for nurse and midwife prescribers: London, NMC 3

requirement of medical mentors for NISPs. These standards expect nurse prescribers to have sufficient knowledge and competence in their therapeutic area for prescribing, and to gain expertise for prescribing within their clinical areas. 4.4 Specifically, the NMC Standards (2006) require nurse prescribers to: Assess a patient/client s clinical Decide on management of presenting condition condition and whether or not to prescribe Undertake a thorough history, Identify appropriate products if including medical history and medication is required medication history, and Advise the patient/client on effects and diagnose where necessary, risk including over-the-counter Prescribe if the patient/client agrees medicines and complementary Monitor response to medication and therapies lifestyle advice 4.5 Furthermore, the NMC has acknowledged that when employers consider the suitability of a nurse or midwife to develop skills in prescribing, it is the employers responsibility to ensure that the registrant is able to apply the prescribing principles to their own area of practice (NMC 2006). Practitioners and managers should ensure that processes have been developed to utilise these skills on successful completion of the programme. It is generally accepted that these pathways should be considered before applying for the NISP (V300) programme, to ensure that the practicalities have been thought through and that reflects the strategic service direction for the HSC Trust. 4.6 In terms of professional and corporate governance, it is important that the prescribing of medicines is carried out by appropriately qualified, trained and competent staff. The NMC (2006) Standards outline that these staff must identify their parameters of prescribing which, in NI, will be approved through the HSC Trust Drugs and Therapeutic Committees. This should ensure compliance with all legislative requirements, including professional standards, good practice, evidence-based guidance and patient safety. 4.7 In 2007, NIPEC was asked to undertake A Review of the Implementation of the Nurse Prescribing Role 6. This review made seven recommendations (Appendix Two) which aimed to further facilitate the achievement of the Nurse Prescribing Role. 4.8 Since that review, however, there have been significant reconfiguration changes to the structure of the health service of NI. The recommendations from that report will be reviewed later in this document. 6 NIPEC (2007). A Review of the Implementation of the Nurse Prescribing Role. Belfast, NIPEC, www.nipec.hscni.net 4

4.9 Initially, in the implementation of the V300 nurse prescribing programme (NISPs), there was a designated limited formulary, which many nurses felt restricted their practice. Since 2012, however, the legislation has been amended to allow a NISP to prescribe any medicine (licensed or unlicensed) for any medical condition that meets the needs of patients within his/her area of competency. There are exceptions which include Cocaine, Diamorphine, Dipipanone and their salts, or products containing these substances, for a person addicted to any controlled drug listed in the Schedule 1973. 4.10 Non-Medical Prescribers (NMPs) is a term which encompasses nurses, midwives, pharmacists and allied health professionals (AHP). In the remainder of this document, to aid the reader NISPs and CPNPs will be referred as NMPs, unless otherwise stated. 5.0 NURSE PRESCRIBING EDUCATION PROGRAMMES 5.1 In NI, the NMP education programmes are accessed through the University of Ulster (UU) and Queens University Belfast (QUB). These programmes are approved, by the NMC and are recordable qualifications on the NMC register. Table 2 below refers again to the programme code and qualification. TABLE 2 - CODE AND QUALIFICATION Programme Code Qualification V100: Community Practitioner Nurse Prescriber V150: Community Practitioner Nurse Prescriber (without Special Practice Qualification or Specialist Community Public Health Nurse) V300: Nurse Independent / Supplementary Prescriber 5.2 Prior to the acceptance of a candidate on to the NISP / V300 programme, HEIs require that he/she is currently registered on the NMC register. HEIs in NI also require applicants to hold 120 credits before accessing the programme and to have a satisfactory Access NI check. In line with the NMC (2006) Standards, therefore the applicant must also: have at least three years' experience as a practising nurse, midwife or a specialist community public health nurse, and be deemed by their employer as competent to undertake the programme. Of these three years, the year 5

immediately preceding the application must have been in the clinical field in which the candidate intends to prescribe have employer support for undertaking the programme have a background of specialist knowledge in the area of practice in which they intend to prescribe have a designated medical practitioner who meets eligible criteria for medical supervision of nurse prescribers and who have agreed to provide the required term of supervised practice be in a role that enables the candidate to prescribe and where the necessary, infrastructure is in place to permit prescribing. 5.3 Safeguarding Patients 7 (2001) recommended there should be mandatory continuous professional development requirements for all prescribers. The NMC's Principles for Continuous Professional Development (CPD) for Nurse and Midwife Prescribers 8 and the NMC Prep Requirements 9 assist nurses and midwives to meet the recommendations of Safeguarding Patients (2001) and to: o o o o provide a high standard of practice and care keep up to date with new developments in practice think and reflect demonstrate that they are keeping up to date and developing their practice 5.4 In addition, the National Prescribing Centre has developed a single competency framework 10 for any prescriber, regardless of professional background. This consolidates existing profession-specific prescribing competency frameworks. 5.5 Educational updates in NI are provided by QUB, UU, Clinical Education Centre (CEC), and there are also several online resources that can be accessed for example: the Health and Social Care Board (HSCB), through the Primary Care Intranet 11 for primary care providers and the Medicines NI 12 and, Northern Ireland Centre for Pharmacy Learning and Development (NICPLD) websites. 13 7 Safeguarding Patients (2001).The Government s response to the recommendations of the Shipman Inquiry s Fifth Rreport and to the recommendations of the Ayling, Neale and Kerr / Haslam Inquiries. 8 NMC (2008). Guidance for Continuing Professional Development for Nurse and Midwife Prescribers http://www.nmcuk.org/documents/guidance/nmc-guidance-for-cpd-for-nurse-and-midwife-prescribers.pdf (accessed Nov 2013) 9 Nursing and Midwifery Council (2011). The Prep handbook London NMC 10 National Prescribing Centre (2011). A single competency framework for all prescribers http://www.npc.co.uk/improving_safety/improving_quality/resources/single_comp_framework.pdf (accessed Nov 2013) 11 http://primarycare.hscni.net/pharmacy_medicines_management.htm accessed Jan 2014 12 http://www.medicinesni.com/ accessed Feb 2014 13 https://www.nicpld.org/ accessed Feb 2014 6

5.6 The HSC Board's Pharmacy and Medicines Management Team is tasked to provide and lead on Medicines Management for the primary care sector and, in the HSC Trusts. The latter is normally provided in Trusts via Medicines Governance Committees. 5.7 The HSC Board Pharmacy and Medicines Management Team has a specific role in medicines management, medicines safety, pharmaceutical public health and pharmaceutical services. Examples of its work include: Direct interaction with primary care practitioners through Medicines Management Advisers in each Local Commissioning Group (LCG) area Review of medicines usage in primary care through an information hub in Business Services Organisation (BSO) Supporting the reporting of, monitoring and managing adverse incidents relating to medicines including disseminating learning Management of the community pharmacy contract and commissioning pharmaceutical services in primary and secondary care. 7

6.0 REGISTRANTS IN NORTHERN IRELAND 6.1 Nurse prescribing in NI was initiated in 1999 and for the purpose of this review, the NMC was contacted, with a request to confirm numbers of nurse prescribers 'live' on the professional register. Table 3 set out the number of nurses on the NMC register, per programme. It is important to note that this only includes those nurses whose registered home address is in NI. TABLE 3 - NURSE PRESCRIBERS 'LIVE' (NI) WITH NMC REGISTER [V100] Community Practitioner Nurse Prescriber 1226 [V150] Community Practitioner Nurse Prescriber (without Special Practice Qualification or Specialist Community Public Health Nurse) 4 [V300] Nurse Independent / Supplementary Prescriber 518 Total 1748 These numbers are current as of 26th November 2013: Source NMC. 6.2 It is worth mentioning that in NI the V150 programme was not added to the prospectus until 2013, and so the four registrants on the NMC register with V150, living in NI, must have acquired the qualification elsewhere. It is also important to note that there are nurses who are in the possession of both the V100 and V300 qualifications, who are included in both sets of figures, possibly leading to a degree of double counting. 7.0 ENGAGING WITH PROFESSIONALS 7.1 In order to capture the status and impact of nurse prescribing, engagement with nurse prescribers and the HSC Employers was essential. The Steering Group designed two questionnaires, one for nurse prescribers (Appendix Three), a second for HSC employers (Appendix Four). It was decided that the questionnaires should be conducted online, via SurveyMonkey software. In addition, a stakeholder engagement event was organised to capture qualitative information. 7.2 The online SurveyMonkey links were posted on NIPEC s home page, and information flyers (Appendix Five) were sent out via the Executive Directors of Nursing, and to the members of the Steering Group for the purpose of wider distribution to Nurse Prescribing Leads and Nurse Prescribers within the HSC. 7.3 The online survey links were accessible via NIPEC's website from 8th July 2013 to 1st September 2013. It was subsequently agreed by the Steering Group, however, to 8

extend access to the SurveyMonkey links until 30th September 2013. This extension was necessary because the survey period included the summer months and with the aim to target nurse prescribers employed in GP Practice. The extension, therefore, altered the completion date of the project by one month. 7.4 At the end of the survey period (30th September), a total of 219 individuals had responded to the questionnaire, and all five Health and Social Care HSC Trusts had also replied. The stakeholder engagement event was held on 5th November 2013, when a total of 55 professionals attended, 45 of whom are currently employed as nurse prescribers. 8.0 ENGAGING WITH PATIENTS/CLIENTS 8.1 It was acknowledged from the outset of this project that engaging with patients would be difficult, as nurse prescribing represents a small proportion of prescribing activity in NI. Indeed some patients may or may not be aware of who has prescribed medication for them. It is relevant to note that this however should not be the case, if prescribers introduce themselves to their patients/clients. 8.2 At the commencement of the project, therefore, a request to join the Steering Group was sent to the HSC Patient and Client Council (PCC). Unfortunately, due to its programme of work, the PCC were unable to accept this invitation. 8.3 The PCC, has a membership scheme, and a quarterly newsletter is circulated to their wide membership throughout NI. An article (Appendix Six) was submitted to the PCC for inclusion in this newsletter. The article outlined the purpose of assessing the impact of nurse prescribing and invited those interested in sharing their views/experiences to make contact. NIPEC's contact details were included in the article. Nevertheless, despite several attempts at advertising, unfortunately no contact from service users was received via this process. 8.4 The difficulty in obtaining users' experience of nurse prescribing was discussed at length during each of the Steering Group meetings. It was agreed, however, to adapt a questionnaire that is currently used to capture patient/service users views in the evaluation of students undertaking a nurse prescribing education programme. Approval was sought via Queens University Belfast (QUB) to adapt the questionnaire (Appendix Seven) to acquire the information needed for the purpose of this project. This adapted questionnaire was circulated to the Steering Group members for wide distribution within the HSC Trusts. 9

8.5 Whilst there was a slow response, initially, to the adapted questionnaire, a total of 150 completed forms were subsequently returned. The patient/carer respondents were drawn from a wide range of services, including, cardiology; primary care; mental health; respiratory; dermatology; acute pain clinic and through Macmillian services; smoking cessation clinic; cardiac catheterisation laboratory; vascular and diabetes. 9.0 FINDINGS 9.1 In order to assess the impact and current status of Nurse Prescribing in NI, as described earlier, various methods were used to capture the information required. These included: Online questionnaires via SurveyMonkey Professional stakeholder engagement event (5th Nov 2013) Nursing and Midwifery Council (NMC) Business and Contracts, DHSSPS Student evaluation from Nurse Prescribing Educational Programmes Service user/carer questionnaires, and the Business Services Organisation 9.2 The collective findings from all of the above form the content of this report. Information collated was then reviewed, and themed under the following headings: Education Practice Support and Professional Development Impact on the patients/carers and their experiences 10.0 EDUCATION 10.1 The theme of education included the process of selection of candidates for the programmes. 10.2 Selection of candidates for the programmes HSC Trusts were asked about the processes which are in place for the selection/recruitment of nurses wishing to complete a nurse prescribing programme. Responses indicated that there was a variety of processes, including self-selection, identification through training needs analysis, to a more rigorous process to gain a place as described below. 10.3 One HSC Trust advised that applicants wishing to complete a prescribing programme have to demonstrate that they have had an initial discussion with their line manager. 10

In addition, and apart from satisfying the HEI's entry requirements, applicants are also required to have expressed consideration of the benefits to patients through this advancement of their nursing practice. This Trust also request that applicants take into account the wider service requirement in their area of clinical practice, including other non medical prescribers and demonstrate how they will be in a position to prescribe on completion of the programme. 10.4 Another HSC Trust reported that it required applicants requesting to commence a Non Medical Prescribing (NMP) programme, to submit an application form to the nonmedical prescribing governance group, prior to applying for a place on the commissioned education programme. This Trust's document requires the candidate to describe how the nurse prescribing element would enhance service provision and how it is aligned to the HSC Trust Service Delivery Plan. This form requests details such as: has the application been submitted in line with the workforce and service delivery plan for the clinical area? identification of an eligible mentor and what medications are anticipated to be prescribed on completion of the course? 10.5 Training and Educational Programmes Through online survey, respondents were asked which nurse prescribing programme they had completed. 216 of the 219 respondents answered this question, 149 (69%) completed the Nurse Independent/Supplementary Prescriber (NISP - V300 programme) and 54 (25%) the Community Practitioner Nurse Prescriber (CPNP) V100 programme. The remaining 13 (6%) respondents indicated that they completed both the programmes. 10.6 Information was requested from the Business and Contracts Manager for Education Commissioning (DHSSPS) on the numbers completing both V100 and V300 commissioned programmes in an average year. Table 4 sets the detail of the number of places requested and unused per Trust on the various programmes in 2012/2013. 10.7 Table 4 also illustrates the number of nurse prescribers who completed District Nursing (DN) and Health Visiting (HV) for the same period (2012/2013). 11

TABLE 4 - DHSSPS EDUCATION COMMISSIONED PROGRAMMES (2012/13) BHSCT NHSCT SEHSCT SHSCT WHSCT TOTAL PROVIDER Ulster/QUB Ulster PROGRAMME NMP (Non Medical Prescribing) formerly Nurse Independent and Supplementar y Prescribing Community Practitioner Nurse Prescribing (V100) Stand Alone Module YEAR Number of places requested Unused places Number of places requested Unused places Number of places requested Unused places Number of places requested Unused places Number of places requested Unused places Number of places requested 2012/13 14 2 6 0 5 2 9 2 4 1 38 7 2012/13 0 0 2 0 0 0 0 0 0 0 2 0 Unused places TOTALS 14 2 8 0 5 2 9 2 4 1 40 7 Ulster Ulster Health Visiting - SCPHN Specialist Practitioner: District Nursing (SPDN) 2012/13 2 n/a 3 n/a 7 n/a 7 n/a 4 n/a 23 n/a 2012/13 4 n/a 4 n/a 0 n/a 6 n/a 1 n/a 15 n/a TOTALS 6 n/a 7 n/a 7 n/a 13 n/a 5 n/a 38 n/a 12

10.8 Evaluation of Educational/Training Programmes Individual respondents to the online survey reported that they enjoyed the programmes. This was supported by those attending the stakeholder engagement event held on 5th Nov 2013. A discussion at the stakeholder event highlighted that the programmes were seen as "difficult" and "challenging" to complete. However, this was balanced by the view that the programmes had been a good investment of time, in order to gain the required knowledge and skills. In turn this was viewed by many as having an impact on, and improving patient care/experience. Some of the attendees at the event noted that the allocation of approved study leave seemed hard to come by'. It seemed that there is no standardised regional approach to approved study leave. On the other hand it was also stated that some employers enabled staff to attend the programmes by reducing caseload commitments allowing for study leave. 10.9 Positive messages, regarding what was liked most about the programmes included the different types of scenarios - namely, health assessments and the various examples of 'prescribing in practice' sessions. These included topics such as 'prescription writing', taught at that stage by the then four Health and Social Services Boards' Nurse Prescribing Advisors. These were reported as being very informative and necessary for practice. 10.10 There were a few comments on how improvements to the programmes could be made. The length was cited as being 'too long', while other comments related to the intensity that there seemed to be too many modules squeezed into the programmes. The HEIs have explained, however, that the number of modules for V300-NMP is average for part-time education programmes. Additionally, there were suggestions that the programmes should include specific learning materials related to their respective 'specialist practice' areas. This topic was also discussed at length at the stakeholder event, where it was stated that the nurse prescribing programmes focused too much on the acute, and not enough on specialist practice areas. Others suggested an improvement to the preparation materials before commencing the programmes. 10.11 It is important to note that the education programmes are based on a generic model. For the V300 programme, medical mentors are there to support those employed in specialist practice. Additional comments expressed at the event highlighted that, in recent years, there was a recognition that the programmes had been a revised resulting in the inclusion of the 'practical sessions'. These comments were also reflected in the student evaluations received from HEI's, which confirmed that annual course reviews are completed and that programmes are adapted accordingly. 13

10.12 One-day update by the HEIs for nurse prescribers (V300) has been commissioned by the DHSSPS since 2012. At the one-day update event in December 2013, there were many very positive comments, for example:- Case studies and real life scenarios excellent, as was the interaction with speakers and audience Good presentations, especially on the various supporting websites Nurse prescribing lead made excellent, practical points Generally an excellent update - good overview of the many aspects of NMP delivered by knowledgeable speakers Legal aspects of the nurse prescribing role very informative Generally a beneficial day. 10.13 In addition, there were a number of comments from the event in December 2013, requesting more updates, for example: 'These updates need to be held twice a year to allow as many prescribers as possible to get to one. Hosting yearly limits the numbers of nurse prescribers who can get, due to work commitments'. 10.14 HSC Trusts are required to submit the requested number of places on the education programmes to the DHSSPS at the start of the Commissioning process normally in September (see Diagram 1 Commissioning Cycle). Occasionally, however, some of these places are not taken, this leads to a process of trying to fill all places and can result in inappropriate candidates being selected onto the programmes. Diagram 1: Commissioning Cycle (DHSSPS / NIPEC 2008) 14

10.15 Updates for Nurse Prescribers As mentioned earlier, updates for Nurse Prescribers are a relatively recent addition, commissioned by DHSSPS since 2012. These are not identified as a mandatory requirement. Nonetheless the importance of keeping up to date with current practice and legislation surrounding prescriber s competencies is an important aspect of the role, especially in terms of patient safety. 10.16 Clearly outlined in the National Prescribing Centre (NPC) single competency framework (Competency 4: Safe Practice) 14, practitioners must assess themselves to be 'aware of their own limitations and not compromise patient safety as illustrated by the following extract:- 40. Only prescribes a medicine with adequate, up-to-date awareness of its actions, indications, dose, contraindications, interactions, cautions, and side effects (using, for example, the BNF/BNFC). 41. Accurately calculates doses and routinely checks calculations where relevant, for example for children. 42. Keeps up to date with advances in practice and emerging safety concerns related to prescribing. 14 National Prescribing Centre (2011). A single competency framework for all prescribers. http://www.npc.co.uk/improving_safety/improving_quality/resources/single_comp_framework.pdf (accessed Nov 2013) 15

11.0 PRACTICE 11.1 Place of Employment Data in respect of place of employment of nurse prescribers is included as a pie-chart (diagram 2) below. 191 of 219 responses were received to this question. DIAGRAM 2 - PLACE OF EMPLOYMENT SHSCT 37(19.5%) GP 17(8.9%) Place of Employment 55 (29.9%) BHSCT SEHSCT 27(14.2%) 12 (6.3%) 42 (22.1%) 11.2 Area of Practice WHSCT NHSCT Of those who completed the questionnaire, 105 (55%) reported that they currently work in community, 62 (32.5%) in hospital and three (1.6%) in private practice. 21 (11%) of respondents reported that they worked in both community and hospital settings. 11.3 It is worth reminding readers that nurse prescribing programmes are commissioned through the DHSSPS/HSC Education Commissioning process. Three respondents indicated that they were currently employed in private practice, suggesting that these respondents must either have completed a nurse prescribing programme while employed in the HSC (NI), or elsewhere in the UK, as the DHSSPS education commissioning process does not include private practice. 11.4 Registered to prescribe Respondents were asked if they were registered to prescribe within their HSC Trust or with their employer. Of the 190 who answered this question, 183 (96.3%) reported that they were registered to prescribe. Those who said they were not registered with their HSC Trust or employer gave the following reasons: Currently not in a practising role Not sorted with manager yet 16

Awaiting registration I do not know I am new in post, I removed my name as I require to be in post for one year and competent in post prior to prescribing. Previously active on the register as a thoracic nurse prescriber I am not actually prescribing - letters of recommendation to GP's only I am awaiting registration 11.5 A similar question was put to Trusts in order to determine if the Trusts could account for the number of nurses registered to prescribe within their organisation. At the time of this project, a new online registration system was being implemented in the Trusts. As a result accuracy of the information may not be up to date. Table 5 sets out the number of nurse prescribers per Trust as reported. TABLE 5- NUMBER OF NURSE PRESCRIBERS PER TRUST TRUST NISP Community NP BHSCT 55 173 NHSCT 35 119 SEHSCT 43 58 SHSCT 74 143 WHSCT 75 129 11.6 There are approximately 80 General Practitioner (GP) employed nurses who have completed the programme and are registered to prescribe. Approximately 10 of these nurses work for more than one Practice, thus increasing the number of Practices with a nurse prescriber to approximately 90. Updated information from Business Services Organisation (BSO), (April-Oct 2013) indicates that 74 individual nurses are prescribing. 11.7 Non-medical prescribers registered to prescribe in primary and community care settings need to be allocated a Cypher number before they can order prescriptions. The Cypher number will be pre-printed on hand written prescriptions (HS21 forms) or computer generated if using a GP clinical system. This enables the setting up of automatic monitoring processes, and identifies individual prescribers. 11.8 The BSO confirmed the number of nurses registered to prescribe in primary care and community settings. As of Jan 2014, Table 6 demonstrates the number of nurse prescribers per HSC Trust over the past 11 years and sub-divides these into District 17

Nurse (DN), Health Visitor (HV) and Nurse Independent / Supplementary Prescriber (NISP - V300). TABLE 6 - BSO's Register NUMBER OF NURSE PRESCRIBERS/PER HSC TRUST/BY YEAR KEY: DN (District Nurse) HV (Health Visitor) NISP (Nurse Independent Supplementary Prescriber) TRUST Sub Divide Year 2014 '13 '12 '11 '10 '09 '08 '07 06 '05 '04 BHSCT DN HV NISP Total 89 63 22 174 85 58 22 166 75 42 23 140 69 40 22 131 68 40 16 124 64 39 13 116 57 35 11 103 46 28 9 83 29 25 5 59 25 22 5 52 24 21 0 45 NHSCT DN HV NISP Total 30 114 23 167 29 114 22 165 36 123 16 175 32 118 13 163 37 116 6 159 37 109 6 152 37 98 6 141 34 87 4 125 29 69 2 100 26 64 2 92 22 62 0 84 SEHSCT DN HV NISP Total 57 57 17 131 54 55 17 126 54 54 18 126 59 53 18 130 59 49 14 122 53 48 10 111 47 45 7 99 39 37 5 81 32 34 3 69 27 33 0 60 25 32 0 57 SHSCT DN HV NISP Total 60 49 21 130 60 49 21 130 63 62 19 144 62 62 20 144 58 62 15 135 58 62 15 135 48 52 11 111 39 50 10 99 32 46 6 84 32 43 5 80 31 42 0 73 WHSCT DN HV NISP Total 41 63 15 119 41 63 15 119 44 63 16 123 41 61 15 117 37 59 14 110 32 57 10 99 31 57 9 97 26 46 9 81 24 44 4 72 21 34 4 59 18 33 1 52 Grand Total 721 706 708 685 650 613 551 469 384 343 311 11.9 Table 7 (a) demonstrates NMPs by Cypher number; this includes HSC Trust employees and practice employees. Table 7 (b) converts this information into a linegraph for contrast. 18

TABLE 7 - (a) NURSE PRESCRIBERS BY CYPHER No. Trust Registered Nurse Prescribers (by Cypher) Trust employed YEAR Trust _Name Sub Type 2014 '13 '12 '11 '10 '09 '08 '07 BHSCT DN 89 87 75 71 68 64 57 46 BHSCT HV 63 59 42 38 40 39 35 28 BHSCT NISP 22 24 23 22 16 13 11 9 NHSCT DN 30 41 36 32 37 37 37 34 NHSCT HV 115 126 126 121 117 109 98 87 NHSCT NISP 23 23 16 13 6 6 6 4 SEHSCT DN 57 60 54 59 59 53 47 39 SEHSCT HV 57 55 54 53 49 48 45 37 SEHSCT NISP 17 19 18 18 14 10 7 5 SHSCT DN 61 73 63 62 58 58 48 39 SHSCT HV 49 62 62 62 62 62 52 50 SHSCT NISP 21 24 19 20 15 15 11 10 WHSCT DN 41 46 44 41 37 32 31 26 WHSCT HV 63 63 63 61 59 57 57 46 WHSCT NISP 15 16 16 15 14 10 9 9 Total 723 779 711 688 651 613 551 469 Board BHSC NHSC SHSC WHSC Practice Employed Nurses Year Sub Type 2014 '13 '12 '11 '10 '09 '08 '07 NISP 34 33 33 29 25 23 20 14 NISP 27 26 25 21 21 19 15 13 NISP 14 10 10 9 9 9 9 6 NISP 19 16 15 15 15 12 9 8 Total 94 85 83 74 70 63 53 41 19

TABLE 7 (b) Nurse Prescribers 400 Nurse Prescribers Number of Nurse prescribers 350 300 250 200 150 100 50 DN HV NISP GP Employed Nurses 0 2014 2013 2012 2011 2010 2009 2008 2007 11.10 Respondents to the online survey were asked if they were registered as nurse prescribers with the Nursing and Midwifery Council (NMC). 189 answered, with 188 (99.5%) stating that they were on the NMC register. The respondent who submitted a negative response did not provide a reason. 11.11 Respondents were asked to identify their area of practice. A total of 181 answered this question. Table 8 below demonstrates the 'top' 12 areas most frequently identified It is also interesting to note that 8 (4.4%) stated that they were 'not prescribing', but are using their prescribing skills at out-patient clinics by making written recommendations in relation to medications, to the patients' GP. TABLE 8- AREA OF PRACTICE Area Number Response Percent 1. Cardiology 27 14.9% Diabetes 27 14.9% 2. Nurse Practitioner 26 14.4% 3. Respiratory 20 11% 4. Care of Older Person 19 10.5% 5. District Nursing 18 9.9% 6. Pain Management 16 8.8% 7. Health Visiting 14 7.7% 20

8. Children's 12 6.6% Palliative Care 12 6.6% Practice Nurse 12 6.6% 9. Tissue Viability 11 6.1% 10. Mental Health 10 5.5% 11. Emergency Care 9 5.0% General Medicine 9 5.0% Public Health Nursing 9 5.0% Sexual Health 9 5.0% 12. Gastroenterology 6 3.3% 11.12 Active prescribing Respondents were asked if they actively prescribed'. This was defined by writing on a kardex or prescription pad (known as HS21). The breakdown of the completed answers was as follows: 144 (75.8%) answered YES 46 (24.2%) answered NO Responses from the 46 who replied No included: 1. No prescription pad available - 11 respondents 2. Practical difficulties no support - 9 respondents 3. Recommending medications - 8 respondents 4. No Trust Policy - 3 respondents 5. Awaiting registration - 2 11.13 In addition, respondents were asked for suggestions to facilitate their re-activation of independent prescribing. A number of important suggestions were offered :- Better support structures Training and updates, prescribing forum, tackling barriers to prescribing Practical policies and guidelines; at present, we would have to be in touch with GP within 24 hrs which would be impractical- it is easier to recommend (NB: NMC 2006 Standards state notification to GP within 48hrs). Improve information systems Limited educational support since completing course. 21

Need for support similar to what GPs have, if not more; They have a GP Clinical system to check interactions with other drugs etc, nurse prescribers are left without these systems (NB: Comment received from Trust employee) Provision of a regional non medical prescribing forum and a yearly update Programme of updates, prescribing parameters and regular support The process to get registered in the Trust is quite lengthy. Requirement to have three signatures and it is now with the Lead for prescribing. This process could be more streamlined Need for a review of the current situation and allow nurse prescribers to prescribe on prescription pads at Nurse Led Clinics, regardless of where these take place; this would improve the service we provide to patients and mean that patients start new medication earlier. 11.14 It is apt to note that the term active prescribing, however, sparked a great deal of discussion at the stakeholder event. Some registrants who had completed a prescribing programme, and who were recommending medications to another professional, for example, General Practitioner, felt very strongly about their role and responsibilities. They described this as a shared activity. In particular, they expressed their annoyance at the notion that they were deemed by some to be not actively prescribing. This term needs further explanation/understanding as explained in subsequent sections of this report. 11.15 Furthermore, comments from nurses who 'recommend' indicated that, in the course of their practice, they performed health assessments to understand fully a patient s condition and medication needs. These registrants stated that they require an indepth understanding of the pharmacokinetics and adverse effects of any drug, in order to recommend medication for the individual needs of their patients. They expressed their opinion that it was the completion of a nurse prescribing education programme had provided the necessary pharmacological knowledge of medications, to enable them to recommend medication safely. They saw this as one of their fundamental responsibilities regarding patient safety. 11.16 The extent to which nurses and pharmacists who qualify as prescribers use their prescriptive authority has been the subject of debate in the literature 15. A recent study into the trends in nurse prescribing in primary care, found that while the number of 15 Department of Health Policy Research Programme Project 016 (2010) Evaluation of nurse and pharmacist independent prescribing Southampton http://eprints.soton.ac.uk/184777/3/enpipfullreport.pdf) 22

nurses registered to prescribe has increased the number of nurses actively prescribing is declining. 16 11.17 Within the NMC Standards for Nurse Prescribers, 17 there appears to be no guidance, or current position statement, on recommending medications for others to prescribe. The General Medical Council 18, however, is very clear about who holds the responsibility in relation to the recommendation of medication by one professional to another. The GMC states: 'If you prescribe at the recommendation of another doctor, nurse or other healthcare professional, you must satisfy yourself that the prescription is needed, appropriate for the patient and within the limits of your competence' (GMC 2013). This is also evidenced by advice from the Medical Protection Society 19. 11.18 A search was also conducted to ascertain if the Royal College of Nursing (RCN) had a position statement on 'recommending medications'. Contact was made to RCN UK and the following statement was provided in relation to professional accountability: " we are of the view that having a register-able qualification infers a particular level of knowledge and therefore accountability for decisions made. In that sense, whether a practitioner recommends or actually prescribes a drug we would still view their practice as being comparable to that displayed by any other non-medical prescriber". 12.0 SUPPORT AND PROFESSIONAL DEVELOPMENT 12.1 Respondents were asked to identify the professional and supporting structures which are available in their place of employment to assist them in fulfilling their prescribing role. They were asked to select, from a number of choices which was the most appropriate supporting structure to them. This meant respondents could have selected one or all from the list. 12.2 190 respondents answered this question and the two most popular choices were email/electronic updates, chosen by 101 (53.2%), and peer support, selected by 89 (46.9%). Pharmacists (for example Hospital/HSCB Medicine Management Advisors) coming in third, as chosen by 67 (35.3%). Table 9 demonstrates this and sets out the ranking status of the other choices. 16 Bhardwa, S. (2014) Trends in primary care prescribing http://www.independentnurse.co.uk/cgi-bin/ accessed March 2014 17 Nursing and Midwifery Council (2006). Standards of proficiency for nurse and midwife prescribers: London NMC 18 General Medical Council (2013). Good practice in prescribing and managing medicines and devices available at http://www.gmc-uk.org/prescribing_guidance 2013 50955425.pdf 19 Medical Protection Society Professional Support And Expert Advice Northern Ireland Factsheet Safe prescribing Advice (April 2013), available at http://www.medicalprotection.org/mps-ni-factsheet-repeat-prescribing-for-gps.pdf 23

TABLE 9- SUPPORT STRUCTURES Rank Support Structures Number Response percent 1 Email or electronic updates 101 53.2% 2 Peer Support 89 46.8% 3 Pharmacists (eg Hospital/HSCB Medicine Advisors) 67 35.3% 4 Professional Nurse Prescribing Forums 56 29.5% 5 Medical Mentors 55 28.9% 6 Supervision 48 25.3% 7 Prescribing Meetings 43 22.6% 8 Management 40 21.1% 9 Regional Prescribing Nurse Advisors 38 20% 10 Lead Nurse (prescribing) 20 10.5% 11 Mentoring 19 10% 12 Buddying 17 8.9% 13 Online Seminars 14 7.4% 13 No Support 14 7.4% 14 Learning Sets 4 2.1% 12.3 The organisational response varied in terms of the supporting structures compared to that which indicated by nurse prescribers in Table 9. More than one choice could be selected. Trusts, however, ranked supervision first (77%); peer support second (66%); and management structures, professional nurse prescribing forums and medical mentors third (55%). 12.4 Organisations were asked to identify if any, time was allocated to supporting the role of the nurse prescriber, as the lead person for prescribing. The majority (3/5) stated 'none' or 'not sure'. One indicated that it was the responsibility of those with an overall management role. Another responded that it had a 0.8 whole-time equivalent (WTE) interim senior manager in a supporting role to nurse prescribers. 12.5 At the recent education update, there were a number of comments summarised below relating to support: Nurse Leads for prescribing should be present throughout the Trusts Better clinical supervision/support - as it was reported that supervision is not always provided in all Trusts 24

Would have liked more information in relation to Patient Group Directions - who, when, where. Would have been good to have had the Nurse Prescriber Leads from all Health Trusts present at the update day There appears to be better learning and support mechanisms in place in other Trusts that does not exist within my Trust 12.6 Lead Nurse for Prescribing The Steering Group decided it was important to ask the respondents if they knew who was the Lead Nurse for Prescribing in their place of employment. 184 respondents answered this question, with 111 (60.3%), indicating they 'did not' know the Lead Nurse for Prescribing in their organisation. 73 (39.7%), however, reported that they did, citing the person's name in their responses. 12.7 Job Descriptions A question was posed to the respondents as to whether their current Job Description outlined their nurse prescribing role. Of the 193 who answered, over half, 118 (61.1%) stated that it was included. It is interesting to note that 23 (11.9%) did not know, or stated that they were not aware if it was in their job descriptions. 52 (26.9%) respondents, however, selected 'No'; it is relevant to note that of those responding negatively, 17 stated that they did have an addenum to their job description, outlining their nurse prescribing role. This would give the impression that some nurses do not realise that the addenum becomes part of the job description. 12.8 Annual Appraisals Annual appraisals are an important process in establishing professional development and training requirements. The Steering Group members were keen to know if the respondents were able to discuss their nurse prescribing role within their annual appraisal process. 189 respondents answered with 146 (77.2%) stating that they were able to discuss their prescribing role with their line manager. Over half (58%) eleborated more on this, explaining that discussions with their managers entailed, how they kept themselves up to date and stated that this gave them an opportunity to identify any training requirements they required. Table 10 provides an example of some of the comments received. 25

TABLE 10- Annual Appraisals/ Personal Development Plans Does your Annual Appraisal/Personal Development Plan give you the opportunity to discuss prescribing issues? Discussed value of Action Learning Sets and requested to attend any lectures for medical/nursing staff to update knowledge and treatments for various diseases I discuss issues with appraiser. The benefit from doing the course has relieved the GP of a lot of work, added to my job responsibility, increasing stress but at times has given me some sense of "personal satisfaction". Not all doctors prescribe "advice". I am a GI nurse endoscopist, performing independent diagnostic and therapeutic endoscopy under sedation and co-sedation. As prescribing is a large part of my role I can discuss any issues at my appraisal. I have great support from my manager, the assistant director of nursing, my medical colleagues and my designated pharmacist Opportunity to discuss relevant prescribing issues regarding neonates e.g. non licence drugs used in neonatology Have discussed with Manager ongoing issue of not being able to prescribe at Nurse led appointments due to position of consultant rooms on hospital premises 12.9 Audit An important aspect of any practice is to measure and monitor quality and safety, through the use of audit. The respondents were asked if their nurse prescribing role was audited. Of the 192 respondents who answered this, 67 (34.9%) stated that it was, with 125 (65.1%) stating that no; audit was not conducted. Of the 67 who selected yes, the majority, 35 (58.3%), confirmed that this was conducted through Trust Clinical Audit activty; whilst 22 (36.7%) used self audit, and a further 3 (5%) reported via e-audit. 12.10 Prescribing Reports To establish the prescribing activity per Trust, information was again requested from Business Services Organisation (BSO) regarding the top items prescribed. Table 11 describes the prescribing activity per Trust as related to the British National Formulary (BNF) Chapters 20. 20 British National Formulary 66 Sept 2013-March 2014 26

TABLE 11: Items prescribed per Trust /Prescriber via British National Formulary TRUST BHSCT NHSCT SEHSCT SHSCT WHSCT Prescriber Type Dressings BNF13 (SKIN) BNF4 (Central Nervous System) Appliances Incontinence Appliances Stoma appliances Unclassified BNF15 Anaesthesia BNF5 Infections Total 19920 3444 188 951 547 520 362 176 86 92 DN 17674 2585 6 830 471 473 320 152 8 76 HV 13 524 176 0 0 2 2 0 64 3 NISP 2233 335 6 121 76 45 40 24 14 13 Total 981 1041 212 45 22 14 14 1 108 26 DN 932 150 1 18 17 13 7 1 0 2 HV 8 868 174 0 0 1 6 0 63 13 NISP 41 23 37 27 5 0 1 0 45 11 Total 9621 1832 125 989 431 734 237 121 257 90 DN 8493 1418 1 918 388 633 219 105 2 52 HV 3 120 24 0 0 0 0 0 16 0 NISP 1125 294 100 71 43 101 18 16 239 38 Total 12853 2164 182 1297 972 401 816 56 48 49 DN 11388 1747 5 1129 933 364 790 26 0 6 HV 2 121 16 0 0 0 1 0 17 2 NISP 1443 290 161 168 39 37 25 30 31 41 PN 20 6 0 0 0 0 0 0 0 0 Total 18701 3190 7155 1276 580 583 425 99 43 208 DN 18610 2540 2003 1173 580 528 316 98 1 118 HV 19 594 1980 2 0 1 16 0 29 1 BNF1 GI Systems) NISP 72 56 3172 101 0 54 93 1 13 89 Grand Total 62076 11671 7862 4558 2552 2252 1854 453 542 465 27 Prescriber Type: DN- District Nurse/ HV-Health Visitor NISP- Nurse Independent Supplementary Prescriber

12.11 Table 12 illustrates a breakdown of the average number of items prescribed annually, by prescriber. This table demonstrates that GP employed nurse prescribers annually prescribe more than the other nurse prescribers collectively. TABLE 12:-NUMBER OF ITEMS PRESCRIBED BY PRESCRIBER YEAR 2013 2012 2011 2010 2009 Trust Presc riber No of Items Average items per prescriber No of items Avg / presc No of items Avg / presc No of items Avg / presc No of items Avg / presc BHSCT DN 23336 268 22692 303 20689 291 17892 263 16250 254 HV 386 7 791 19 798 21 1042 26 999 26 NISP 3008 125 2958 129 665 30 1102 69 1506 116 NHSCT DN 856 21 1144 32 1049 33 6006 162 9601 259 HV 745 6 1167 9 1381 11 1565 13 1952 18 NISP 301 13 371 23 212 16 163 27 370 62 SEHSCT DN 12717 212 12295 228 12323 209 12213 207 11685 220 HV 140 3 180 3 193 4 225 5 345 7 NISP 2064 109 2466 137 1804 100 1086 78 916 92 SHSCT DN 13952 191 16412 261 17545 283 15922 275 12371 213 HV 241 4 162 3 158 3 286 5 836 13 NISP 2635 110 2391 126 1643 82 1487 99 1605 107 WHSCT DN 29744 647 26098 593 21239 518 17127 463 17831 557 HV 2366 38 2665 42 2711 44 1874 32 1756 31 NISP 4500 281 4708 294 4901 327 3072 219 1641 164 TOTAL 96989 125 96500 136 87311 127 81062 125 79664 130 GP practice employed nurse prescribers TOTAL No of Items Aver per prescriber 170702 2275 No of items 16509 4 Aver per prescriber 2025 No of items 14395 2 Aver per prescribe r 1819 No of items 11781 7 Aver prescri ber No of items Aver items per prescri ber 1757 94983 1721 28

12.12 140 responses were received to the question which focused on nurse prescribers having the opportunity to meet with their line manager to discuss their prescribing reports. 96 (68.6%) reported that they did not have this opportunity, with the remaining 44 (31.4%) respondents stating that they 'did have the opportunity to discuss' these reports. 12.13 Prescribing Parameters Nurse prescribers who have completed the V300 (NISP) programme should have discussions with their nurse prescribing leads, and should adhere to the principles outlined in DHSSPS 2006, Improving patients access to medicines 21 :- Ensure that the parameters of an individual s prescribing are agreed between the prescriber, their manager or local professional lead and their employer. Ensure that drug and therapeutic committees are aware of the medicines being prescribed by Nurse and Pharmacist Independent Prescribers. 12.14 In addition the guidance states that Nurses and pharmacists should use clinical supervision arrangements or equivalent as an opportunity for reflection on prescribing, as well as other aspects of practice. 12.15 Enhancement of the Nurse Prescribing Role Respondents were asked for their views on what would enhance their role. Comments received related to the need for better supporting structures; updating of polices and procedures; regular updates and the need for a regional professional nurse prescribing forum. 12.16 A question was asked if any of the respondents 'attended a Nurse Prescribing Forum'? There was a total of 142 answered, of which 45 (31.7%) stated that they did/had attended, however, 97 (68.8%) stated they had not. A supplementary question asked the respondents to describe where the forum meeting were held. 12.17 The most frequently referred to was Trust Prescribing Forums followed by NI Mental Health Nurse Prescribing Forum with a few mentioning those arranged through the Universities. Some respondents commented that although there was awareness of the professional fora taking place,time constraints prevented attendence. 21 Department Health Social Services Public Safety (DHSSPS 2006) Improving Patients' Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the HPSS in Northern Ireland, Dec 2006 29

12.18 During the stakeholder event, attendees were asked to discuss the mechanisms / networks which would enhance their role, under the headings of : Practice Education and Support a) Practice Comments received related to the need for a review and update of the current NMC (2006) Standards of Proficiency for Nurse and Midwife Prescribers. In addition, other comments received included provision of Anti-microbial guidelines/policies in the management of chronic diseases formalised peer group support and, development of a Regional Nurse Prescribers Forum (as not all trusts have one). In community, it was reported that there was constraints due to limited V100 formulary; there was no feedback nor audit of practice carried out, and, no information meetings or updates that staff were aware of. They requested better communication with GPs and an improvement to the interface between primary and secondary care. In addition access to the database for contra indications was requested. GPs have access to this, but, a nurse prescriber can only access this database when working in the GP premises. In those cases when practice involves a nurse prescriber prescribing within a patient home or in other community facilities, the database is not accessible. Under the theme of practice, there was also the recognition that nurses need to be more proactive in the lobbying regarding their position and responsibilities as nurse prescribers. b) Education There was a resounding request to have regular, regional, formal updates and for these to be part of mandatory requirements for continuous professional development (CPD) activities. Additionally, there was a specific request for consideration of 'speciality' only updates. There were also suggestions relating to the need to review the registration process for appropriate courses to make access more robust. Requests to consider the planning and development of regional inter-professional 30

training were also received. It was suggested that the NMC should be approached about reviewing /revising the current standards. There was also a suggestion that NIPEC should be commissioned to develop a competency framework specifically for nurse prescribers in NI. c) Support As previously reported through the online questionnaire, the issues of supporting structures was raised at the stakeholder event. It is interesting to note that prescribers commented that senior managers, who manage nurse prescribers, should have a clear understanding of their role and responsibilities. The role of the former HSS Boards' Prescribing Advisors was recognised as being nurse prescribing champions, and was seen as a great support. These roles had been stood down but many nurse prescribers felt they should be reinstated. Nurse prescribers stated that they viewed the role of the Prescribing Advisor as a significant resource for them both practically and theoretically. In the absence of the prescribing advisor roles nurse prescribers felt there was no regional support or direction to drive nurse prescribing. Specific nurse prescribing supervision was also suggested; and it was viewed that this could be facilitated via group supervision. 13.0 PATIENTS'/SERVICE USERS' EXPERIENCE AND IMPACT ON PATIENTS of NURSE PRESCRIBERS 13.1 The impact on patients of the nurse prescriber's role and its benefits to them, generated many comments, from both the questionnaires completed by nurse prescribers' and at the stakeholder event. It was suggested that nurse prescribing led to enhancements in the quality of care, patient safety, improved speed of treatment and convenience to patients. 13.2 A series of questions was presented on How the nurse prescribing role has made a difference / had a positive impact on patients / service users in relation to: A. Improved access to medications. B. Greater understanding and ability to self-manage. C. Consistency of information. 13.3 The following diagrams (Diagrams 3,4 and 5), illustrate the collective comments received from respondents to the questionnaires and during the discussion held at the stakeholder event with nurse prescribers. 31

DIAGRAM 3- NURSE PRESCRIBING ROLE AND IMPACT UPON PATIENT CARE DIAGRAM 4- NURSE PRESCRIBING ROLE AND IMPACT UPON PATIENT CARE 32

DIAGRAM 5 - NURSE PRESCRIBING ROLE AND IMPACT UPON PATIENT CARE 13.4 The comments received through the online questionnaire and the stakeholder event demonstrated how nurse prescribers view themselves in terms of the impact of their role on their patients and clients. 13.5 Patient/Carer Views Patients were asked through an adapted questionnaire to evaluate both the benefit and the impact of the nurse prescribing role. The questionnaire was circulated in a number of care settings and responses were very positive. A total of 150 responses were received from patients who were in contact with nurse prescribers from cardiology; primary care; mental health; respiratory; dermatology; acute pain clinic and through Macmillian services; smoking cessation; catheterisation laboratory; vascular and diabetes.. 13.6 Table 13 (A) outlines the questions and Table 13 (B) describes the overwhelmingly positive view of patients/carers when in direct contact with the Nurse Prescriber. 33

TABLE 13(A) - QUESTIONS Question 1 Question 2 Question 3 Question 4 Question 5 Question 6 Question 7 Question 8 Did the nurse prescriber introduce himself/herself and explain his/her role? Did the nurse prescriber explain the purpose of the appointment today? Did the nurse prescriber explain the aims of treatment for your condition? Did the nurse prescriber ensure you understood the risks and benefits of the treatment including side effects of any medication? Did the nurse prescriber arrange a review appointment or did she/he explain how you would be followed up? Do you think the nurse prescriber was supportive in managing your treatment? Did the nurse prescriber make you feel you have control and choices in decisions about your treatment? Is there anything that the nurse prescriber could do better in the future? TABLE 13 (B) - PATIENT/ CARER RESPONSES Patients'/Carers' Views 160 150 150 150 147 144 150 150 146 140 120 Number of Patients 100 80 60 40 20 0 0 0 2 5 0 0 0 1 1 0 0 0 0 0 4 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Yes 150 150 150 147 144 150 150 0 No 0 0 0 2 5 0 0 146 Not Sure 0 0 0 1 1 0 0 4 34

13.7 Additional comments received from patients/carers included A great service Great encouragement I am very happy with the advice about my medications Completely satisfied with my experience with the nurse prescriber No improvement required of this service I felt very confident with the nurse prescribing my medication The prescribing nurse explained everything to me, made me feel very relaxed thank you I am very satisfied with this service. The prescribing nurse was a clear communicator, friendly and informative, very professional Very reassuring More than happy with this service I received a contact number for the nurse prescriber reassuring Friendly and explained things very clearly in a language I understood. Didn t feel like I was being rushed. I thought it was only doctors that wrote prescriptions. The nurse giving me what I needed in my home means I can get the treatment I need immediately - a great service. 13.8 The resoundingly positive messages received from the 150 patients, reported in this project are similar to findings in other studies. 22 23 24 This clearly demonstrates, that the role of the nurse prescriber is having an impact on patients. This is in keeping with the DHSSPS 2006 Guidance, 25 which sets out key elements for Independent Prescribers as being to: improve patient care without compromising patient safety make it easier for patients to get the medicines they need increase patient choice in accessing medicines make better use of the skills of health professionals contribute to the introduction of more flexible team working. 13.9 It is recognised that patients are offered many benefits from nurse prescribing, including improved access to appropriate advice and medication, greater understanding and ability to self-manage. 22 Strenner, K.L et al (2011) Consultations between nurse prescribers and patients with diabetes in primary care: A qualitative study of patient views International Journal of Nursing Studies 48(2011) 37-46 23 Jones K et al (2011) The effectiveness of nurse prescribing in acute care Nursing Times Jul 5-2011 Vol 107 no 26 24 Creedon, R. et al (2011) The impact of nurse prescribing on patients with osteoarthritis British Journal of Community Nursing Vol 16, No 8 25 Department Health Social Services Public Safety (2006) Improving Patients' Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the HPSS in Northern Ireland, Belfast, DHSSPS. 35

14.0 MAPPING TO NIPEC (2007) RECOMMENDATIONS 14.1 The Steering Group considered it important to review the previously suggested recommendations on the implementation of the nurse prescribing role, as set out by NIPEC (2007), 26 to decide if these recommendations were still appropriate and relevant in 2014. It was concluded that a number of the recommendations were either fully or partially achieved, but that all continued to have some relevance in 2014. NIPEC Recommendations Number Achieved One Two Five Requires review Three Four Six Seven 15.0 ENGAGEMENT WITH NURSING AND MIDWIFERY COUNCIL 15.1 Following correspondence with the NMC, one of the Standard Development Officers (SDO) requested an opportunity to come and listen to the discussion around this project, because the NMC's Nurse Prescribing Standards being reviewed in 2014. 15.2 Through the SDO, NMC's stated intension is to undertake more engagement, before setting standards, including engagement with the HEIs. The Steering Group welcomed this statement. 15.3 The SDO reported that, the NMC's view is that the current Nurse Prescribing Standards are too long, too detailed and need to be more robust. It was also reported that NMC aims to coordinate a standardised approach across the four UK Countries to reduce any apparent variation in practice. Finally it was reported that the NMC plan to set minimum standards. 15.4 This instigated much discussion, as it was the Steering Group's view that setting the standards to a minimum requirement, leaves too much room for error, especially in the protection of the public. The Steering Group members indicated that their preference would be to set the standards at an appropriate requirement to ensure patient safety is not compromised. 26 NIPEC 2007 A Review of the Implementation of the Nurse Prescribing Role, Belfast accessed www.nipec.hscni.net 36

15.5 The Steering Group members requested that the NMC take this and the need to ensure the new standards would be evidence based into consideration during its' engagement and consultation process. 15.6 The Steering Group members had the opportunity to discuss other issues that have emerged from the project and concluded that they wished to see the following included in the revised standard: Ability to prescribe and administer Personal accountability Assessment of competencies (it was stated that the NMC iskeen to continue to refer to National Prescribing Centre's Framework of Competencies: Steering Group members confirmed that this Framework is already built into the HEIs' programmes) Active prescribing - legislation position statement/standard on recommending medications Transcribing Supervision/support. 15.7 The NMC, through the SDO, reported that the discussion was very useful and offered a solid platform in the review/revision of the standards throughout the UK. 15.8 The NMC also gave an assurance that further engagement would be conducted early in 2014 within NI. It was reported that NMC's Standards for Medicine Management would also be reviewed. 16.0 CONCLUSIONS 16.1 On the basis of the findings of this review, the Steering Group considered the perceived impact on patients as being very positive. 16.2 The Steering Group concluded that whilst overall there have been considerable developments in nurse prescribing, there is a noticeable lack of the presence of 'champions' in the role to provide leadership and delivery on strategic direction. 16.3 Each of the HSC Trust's has a lead nurse prescribing co-ordinator, the Steering Group recognised and emphasised the importance of this role specifically in the support to nurse prescribers 16.4 The imminent revision of the NMC Standards was welcomed by the Steering Group. The concern, however, was expressed regarding the current development of the 37

standards, as it appears it will be driven by a non profession registrant without practice experience of nurse prescribing. 17.0 RECOMMENDATIONS 17.1 On the basis of the findings 1. It is recommended that a Regional Non Medical Prescribers Advisory Group to be established to provide support, advice and review of regional strategy particularly in respect of policies and procedures. In addition this group should be tasked with a responsibility to regularly review audit practices, ongoing continuous professional development and training opportunities for nurse prescribers - linked to NIPEC's 2007, recommendation three 2. Consideration should be given to reinstate the role of Regional Nurse Advisors to provide strategic leadership and direction - linked to NIPEC's 2007, recommendation six 3. There is a requirement to have regular access to resources through improvements in Information Communication and Technology (ICT) in regard to: community based nurse prescribers in particular, who have no access to patient records in the home setting enabling nurse prescribers to access multidisciplinary evidence based therapeutic updates for their CPD accessing the online platform for CPD that is being facilitated through Quality 2020 reviewing the current educational resources, with the intention of developing an interactive online model, suitable for download to mobile devices - linked to NIPEC's 2007, recommendation four. 4. As Transforming Your Care (2011) is implemented, strategic direction is required to ensure that there is an increase the numbers of nurse prescribers in community to provide holistic nursing care assessments for patient prescriptions 5. Careful consideration should be given to a combined training programme for Nurses, Midwives, Pharmacists and Allied Health Professionals mindful of the regulatory standards pertaining to these professions 6. Facilitate the development of leadership opportunities by ensuring Nurse prescriber representation from NI on national committees such as: British National Formulary and NMC review of prescribing standards. 38

APPENDIX ONE Membership of the Steering Group Name Designation Organisation Oriel Brown (Chair) Brenda Devine (Project Lead) Fiona Wright Carolyn Kerr Nurse Consultant Senior Professional Officer Assistant Director Nursing (Workforce) Assistant Director of Nursing (Governance) Public Health Agency (PHA) NIPEC SHSCT NHSCT Liz Campbell Nurse Governance Lead SEHSCT Pauline Casey - (replaced by Brendan McGrath replaced by Bernie Michaelides ) Siobhan Donaghy Representative Nurse Prescribers from Community Sector and Acute sector WHSCT SHSCT Valerie Hall Trust s Nurse Prescribing lead BHSCT Ida Foster Higher Educational Institute OU Rose McHugh Nurse Consultant PHA Marie Glackin Louise Hales Higher Educational Institute QUB Rosario Baxter Higher Educational Institute UUJ Heather Hoyle Higher Educational Institute CLINICAL EDUCATION CENTRE Marina Lupari Council Member NIPEC TOR 1 TOR 2 TOR 3 TOR 4 TOR 5 Terms of Reference To agree the initiative plan and timescales for the project To contribute to the achievement of the initiative aims and objectives To undertake ongoing monitoring of the initiative against the planned activity To agree a mechanism of progress reports from the Project Lead to Chief Nursing Officer/ Directors of Nursing To contribute to the agreed policy and report for submission to the DHSSPS Note: The Steering Group will meet monthly. Membership of Steering Group is non-transferrable except in exceptional circumstances and with prior agreement of the Chair. 39

APPENDIX TWO NIPEC Review of the Implementation of the Nurse Prescribing Role (June 2007) Recommendation one Recommendation two Recommendation three Recommendation four Recommendation five Recommendation six Recommendation seven It is recommended that the DHSSPS, service commissioners and individual Trusts work together to ensure organisational readiness for the implementation of new roles. It is recommended that policy makers, service commissioners and service providers give consideration to the policies and structures that need to be in place for the introduction of new roles resulting from government drivers. It is recommended that Executive Nurse Directors, in partnership with Departmental Nursing Advisory Groups and other key stakeholders, should develop a regional strategy to evaluate the effectiveness of new roles introduced through regional policy directives. It is recommended that the necessary information technology support is fully explored, in advance of new roles being implemented and in collaboration with the regional ICT programme board; and that urgent action is taken to address the specific issues arising in relation to nurse prescribing. It is recommended to health care providers that the implementation of nurse prescribing is supported by job descriptions, KSF outlines, and annual appraisal systems that incorporate nurse prescribing competencies. It is recommended that the new Health and Social Care Authority (HSCA) should ensure continuance of the current Prescribing Adviser capacity in the four Health and Social Services Boards It is recommended that the each new Health and Social Care Trust makes provision for nurse prescribing co-ordinator roles, with the responsibilities clearly defined in job descriptions and dedicated time provided. 40

APPENDIX THREE Nurse Prescribing Individual Questionnaire 2013 No Question Response What Nurse Prescribing programme did you complete? What year did you complete the programme EDUCATION Drop down menu Community Practitioner Nurse Prescriber programme Nurse Independent and Supplementary Prescriber programme Both Drop down menu 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 if before 1999 please state Are there aspects of the educational programme that you liked most? 41

Is there any improvements would you make to the current programme? Organisational Support / Professional Governance Describe the professional development/ support structures available though your organisation that enables you to fulfil your prescribing role? Do you know the Lead Nurse for prescribing in your organisation? Drop down menu - tick what is appropriate to you Mentoring Buddying Management Peer support Lead Nurse (Prescribing) Regional Prescribing Nurse advisors Supervision Pharmacists (eg Hospital/HSCB medicine advisers) Professional Nurse Prescribing Forums Online seminars Medical mentors Prescribing meetings Learning Sets Email or electronic updates None other please comment Yes No If yes please name Does your Job Description include your prescribing role? If not, do you have an addendum to your job description listing prescribing as a role. Does your annual appraisal/ Personal Development Plan give you the opportunity to discuss prescribing issues? Yes No Don't Know Yes No Don't Know Yes No Comments Do you have an opportunity to discuss your Personal Development Plan with your manager Is your prescribing role audited? Comments Yes Yes No No If yes please select: For prescribers in Community Do you receive your Prescribing Reports and have an opportunity to discuss with your line manager? Drop down menu Self audit Trust Clinical audit Peer audit e-audit Other - explain Yes Do you have professional Yes No No 42

indemnity insurance? Do you attend a 'prescribing forum'? Where are you employed? (tick what's appropriate to you) Are you registered with your Trust/employer to prescribe? If so please describe: Practice Drop down menu BHSCT NHSCT WHSCT SEHSCT SHSCT GP Practice Private Out of hours service Other Yes What is your practice area Hospital Community Both Other No If not - why? Are you registered with the NMC as a Nurse Prescriber Answer only - If you are a NISP - which of the following British National Formulary (BNF) Chapters are you prescribing from? (tick what applies to you) Yes No Drop down menu 1. Gastro-Intestinal System 2. Cardiovascular System 3. Respiratory System 4. Central Nervous System 5. Infections 6. Endocrine System 7. Obstetrics 8. Malignant Disease/ Immunos 9. Nutrition and blood 10. Musculoskeletal and Joint 11. Eye 12. Ear 13. Skin 14. Immunological Products and vaccines 15. Anaesthesia 18. Preparations Used in Diagnosis 19. Other Drugs and Preparations 20. Dressings 21. Appliances 22. Incontinence Appliances 23. Stoma Appliances 99. Unclassified 00. Not prescribing What area of practice do you use your Nurse prescribing role in? Drop down menu (Tick what is appropriate to you) Additions (Specify) Care of the older person (Specify) Cardiology (Specify) Children's (specify) Diabetes (Specify) Dementia (Specify) 43

District Nursing (Specify) Emergency care (Specify) Epilepsy (Specify) Gastroenterology (Specify) General medicine (Specify) General Surgery (Specify) Gynaecology (Specify) Haematology (Specify) Health Visiting (Specify) Intensive Care (Specify) Mental Health (Specify) Midwifery (Specify) Nurse practitioner (Specify) Oncology (specify) Out of Hours (Specify) Orthopaedics (Specify) Palliative care (Specify) Pain management (Specify) Practice Nurse (Specify) Prison Nursing (Specify) Public Health Nursing (Specify) Respiratory (Specify) Sexual Health (Specify) Tissue Viability (Specify) others (Specify) not prescribing Are you actively prescribing - that is writing in a kardex or prescription pad) Yes No If not please explain why What could be done to facilitate you to actively prescribe independently - again? When prescribing do you use If you do not use the forms above - do you recommend (i.e advise/suggest/propose) medicines to another to prescribe for the patient? How do you document your recommended medicines/ Drop down menu medicine kardex, prescription form (HS21) Emergency Department flimsy Discharge Script Other - please describe Drop down menu Verbal Written Letter Special recommend forms 44

What are the barriers that prevent you from fulfilling your prescribing role? Medical notes Others Don't document Drop down menu Record Keeping Information technology (IT) Access to patient records Supporting structures - please state Professional Updates no longer in a Nurse Prescribing role limited formulary - (Community Practitioner Nurse prescriber) Others No Barriers For community prescribers only - Are there any formulary limitations that you experience? Do you know the Lead Nurse for prescribing in your organisation? Describe how your prescribing role enhances the quality/safety of patient care? Yes Patient Experience Please give an example No General Comments Do you have any other comments Please describe about any aspects of your prescribing role? For example: CPD Regional Support Multiprofessional What CPD opportunities are available to you Trust Training Multi professional training Commercial Companies National Prescribing Centre None Difficulty in getting released Thank you for your time in completing this questionnaire Steering Group - Nurse Prescribing Project 45

APPENDIX FOUR Nurse Prescribing Health and Social Care Organisational Questionnaire 2013 No Question Response 1 Name of organisation Drop down menu BHSCT NHSCT WHSCT SEHSCT SHSCT Public Health Agency/Health Social Care Board Private (specify) Prison Other 2 Do you have a strategic Yes No plan for developing nurse prescribing practitioners in the future? Please describe 3 Is this Strategic Plan for the development Nurse Prescribers linked to your workforce plan? Yes Please give an example No 4 What processes are in place for the selection of Nurses to the Nurse Independent / Describe / Attach policy 46

Supplementary Prescribing Educational Programme? 5 What processes are there in place for newly qualified Nurse prescribers? How is the Lead Prescribing Coordinator in your organisation for nurse prescribing? 6 Do you know how many nurses in your organisation have trained as a NISP or Community Nurse Prescriber? If so - how many 7 How many Nurses are on your organisation's Prescribing Register? 8 How many Nurses in your organisation are actively Prescribing? Name:- Designation:- Number of NISP Number of Community Nurse Prescribers NISP Community Nurse Prescriber NISP Community Nurse Prescriber Don't know Don't know Don't know Don't know Don't know Don't know 9 Has your organisation an up to date policy which reflects NMC Standards and DHSSPS legislation and guidance in relation to Nurse prescribing? Yes No If no please comment 10 Would your organisation like to see the development of a Regional Non Medical Prescribing Policy? 11 What support is there for Nurse Prescribers in your organisation? Yes NO Drop down menu - tick as appropriate Mentoring Buddying Management Peer support Lead Nurse (Prescribing) Regional Prescribing Nurse advisors Supervision Pharmacists (eg Hospital/HSCB medicine advisers) Professional Nurse Prescribing Forums Online seminars Medical mentors Prescribing meetings Learning Sets 47

None other please comment 48

12 Does your organisation have a professional 'prescribing forum'? 13 Are there systems in place in your organisation that will capture any serious adverse incident/ near misses or significant incidents that has involved the nurse prescribers whilst in their prescribing role? 14 If there has been an incident - Please describe or give a brief synopsis 15 Are there any service development initiatives/projects planned about the role and development of Nurse prescribing in your organisation? If so please describe 16 Do you have any other comments about the role of nurse prescribers in your organisation? 17 What time is allocated for your organisation's lead for nurse prescribing to spend on support and development 18 Are you aware of any barriers to the role of the Nurse prescriber in your organisation Drop down menu Nurse prescribing Forum NMP Forum other if none please comment Comments Yes Yes Yes If yes please describe No No No Thank you for taking the time to complete this questionnaire Name Date Steering Group - Nurse Prescribing Project 49

APPENDIX FIVE Nurse Prescribing in Northern Ireland NIPEC is working in partnership with the Public Health Agency and the Health and Social Care Organisations in Northern Ireland to assess the impact and status of Nurse Prescribing We therefore would appreciate it if you would take some time to complete a questionnaire via survey-monkey. There are two questionnaires: 1. Organisational Leads https://www.surveymonkey.com/s/bsmg2gy 2. Individual Nurse Prescribers https://www.surveymonkey.com/s/by6cb69 They are also available at: www.nipec.hscni.net Having accessed the NIPEC homepage, simply click on the Nurse Prescribing link - you will then be through to the questionnaire. The questionnaire is anonymous and should only take a 10 minutes of your time. Access to the questionnaires will open from Monday 8 th July 2013 and close Monday 30th September 2013 We look forward to hearing from you and thank you for participating. 50